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Direct proof of hepatic hydrothorax by intracavitary contrast-enhanced ultrasound
[Mar 2022]

Direct proof of hepatic hydrothorax by intracavitary contrast-enhanced ultrasound

Christian Jenssen 1,2,
Christine Siebert 1
1 Krankenhaus Märkisch Oderland, Strausberg/ Wriezen, Germany
2 Brandenburg Institute for Clinical Ultrasound, Neuruppin, Germany

Figure 1: Right-sided pleural effusion in a patient with liver cirrhosis and portal hypertension


Figure 2: Only a small amount of perihepatic ascites is detected below the right diaphragm

Direct proof of hepatic hydrothorax by intracavitary contrast-enhanced ultrasound </br> [Mar 2022]

Figure 3: After injection of Saline mixed with only 1 drop of the Ultrasound Contrast Agent SonoVue® into he subdiaphragmatic ascites strong enhancement of the ascitic fluid occurs (↓). A communication between the peritoneal and the right pleural cavity is proven by slightly delayed and less intense enhancement also of the pleural fluid (*)

Video 1: US-guided puncture of the subdiaphragmatic ascites for injection of Saline with SonoVue: the echogenic needle tip is seen below the diaphragm.

Video 2: 10 ml Saline with a single drop of SonoVue is injected using the needle: a very intense enhacement of ascites is observed, followed by occurence of microbubbles also in the right pleural cavity. The echogenic reflex in the pleural cavity is the indwelling pleural catheter. 

1Clinical History
A 71years old male patient was diagnosed with non-alcoholic fatty liver cirrhosis and portal hypertension in 2019. He suffered from arterial hypertension and diabetes mellitus since 2013 and was first hospitalized with an episode of ascitic decompensation in August 2019. Now he was re-admitted to the hospital with dyspnea.
2Image findings & Treatment
On ultrasound, a right-sided pleural effusion was diagnosed (Fig. 1). Diagnostic thoracocentesis and pleural drainage were performed. Only a small amount of perihepatic ascites was found (Fig. 2). Laboratory analysis of the pleural effusion revealed a transudate. A hepatic hydrothorax was suspected. To prove this diagnosis, after antiseptic preparation, ultrasound-guided injection of 10 ml saline with a drop of SonoVue ultrasound contrast agent was performed directly below the right diaphragm into the ascites (Video 1 and 2). In CEUS mode, intense enhancement of ascites was observed. With a slight time delay, isolated microbubbles were first visible in the pleural effusion, followed by a moderate enhancement of the entire pleural effusion as well (Video 2, Fig. 3).
Hepatic hydrothorax as a complication of NASH-cirrhosis with portal hypertension
There are many causes of unilateral pleural effusions. Diagnostic puncture with biochemical analysis, supplemented, if necessary, by cytological and microbiological analyses, allows differentiation into transudate or exudate and can also provide specific clues to the etiology. In this case, a transudate was detected. In most cases, this will be caused by cardiac insufficiency or hypervolemia. Hepatic hydrothorax should be considered in patients with liver cirrhosis and portal hypertension.

Hepatic hydrothorax is a rare clinical manifestation of portal hypertension and was described to occur in up to 15% of patients hospitalized due to decompensated liver cirrhosis and ascites. Hepatic hydrothorax virtually always presents with ascites, but often the amount of ascites is relatively small. Typically, hepatic hydrothorax presents as unliteral right-sided pleural effusion. Pathophysiology is related to direct passage of ascitic fluid from the peritoneal cavity to the pleural cavity through small diaphragmatic defects due to an increased abdominal pressure. These small diaphragmatic defects are not detectable with ultrasound or other imaging modalities (1-3).

Pleural interventions (therapeutic thoracocentesis, indwelling pleural catheters, pleurodesis) have limited efficacy and are associated with a relatively high risk of infection and mortality (4, 5). Hepatic hydrothorax is treated like ascites aiming at the elimination of the fluid in both peritoneal and pleural cavities by maintaining a negative sodium balance, through dietary sodium intake and diuretics (aldosterone antagonists and loop diuretics). In refractory cases, transjugular intrahepatic stent shunt (TIPPS) and liver transplantation are useful treatment options (1-3). br/>br/> OUTCOME
Hepatic hydrothorax may be complicated by spontaneous bacterial pleuritis and is associated with a poor outcome (6). Risk factors for hepatic hydrothorax are recurrent need for paracentesis, a high bilirubin level, diabetes, and non-use of non-selective beta-blockers (7).
5Teaching Points
In most cases, diagnosis of hepatic hydrothorax is indirectly established as a diagnosis of exclusion when patients with liver cirrhosis and portal hypertension have a mostly unilateral-right pleural branch fluid and cardiac, renal, or primary pulmonary etiologies of pleural effusion have been ruled out (1-3). Intracavitary contrast-enhanced ultrasound allows for a fast, and direct diagnosis of hepatic hydrothorax by proof of communication between fluids in the peritoneal and pleural cavities (8-9).
(1) Chaaban T, Kanj N, Bou Akl I. Hepatic Hydrothorax: An Updated Review on a Challenging Disease. Lung. 2019 Aug;197(4):399-405. (2) Lv Y, Han G, Fan D. Hepatic Hydrothorax. Ann Hepatol 2018;17(1):33-46
(3) Benz F, Mohr R, Tacke F, Roderburg C. Pulmonary Complications in Patients with Liver Cirrhosis. J Transl Int Med. 2020 Sep 25;8(3):150-158
(4) Hou F, Qi X, Guo X. Effectiveness and Safety of Pleurodesis for Hepatic Hydrothorax: A Systematic Review and Meta-Analysis. Dig Dis Sci 2016; 61: 3321–34.
(5) Gilbert CR, Shojaee S, Maldonado F, Yarmus LB, Bedawi E, Feller-Kopman D, Rahman NM, Akulian JA, Gorden JA. Pleural Interventions in the Management of Hepatic Hydrothorax. Chest. 2022 Jan;161(1):276-283
(6) Matei D, Craciun R, Crisan D, Procopet B, Mocan T, Pasca S, Zaharie R, Popovici B, Sparchez Z. Hepatic Hydrothorax - An Independent Decompensating Event Associated with Long-Term Mortality in Patients with Cirrhosis. J Clin Med. 2021;10(16):3688
(7) Deleuran T, Watson H, Vilstrup H, Jepsen P. Risk Factors for Hepatic Hydrothorax in Cirrhosis Patients with Ascites - A Clinical Cohort Study. Dig Dis Sci. 2021, Epub ahead of print
(8) Foschi FG, Piscaglia F, Pompili M, Corbelli C, Marano G, Righini R, Alvisi V, Gasbarrini G, Bolondi L, Bernard M, Stefanini GF. Real-Time Contrast-Enhanced Ultrasound – a new simple tool for detection of peritoneal-pleural communications in hepatic hydrothorax. Ultraschall in Med 2008;29:538–42.
(9) Sparchez Z, Radu P, Sparchez M, Vasile T, Anton O, Tantau M. Intracavitary Applications of Ultrasound Contrast Agents in Hepatogastroenterology. J Gastrointestin Liver Dis. 2013 Sep;22(3):349-53

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