PLEURAL EFFUSION OF CIRRHOTIC ORIGIN: PATHOGENESIS, CLINICAL PRESENTATION AND DIAGNOSIS

Background Hepatic hydrothorax is defined as a significant pleural effusion (usually greater than 500 ml) in a cirrhotic patient, without an underlying pulmonary or cardiac disease. The incidence of hepatic hydrothorax varies from 0.4% to 10% according to different reports, and it occurs much more often in the right thorax than in the left. Several observations indicate that the most likely cause of pleural effusions in patients with cirrhosis is the passage of a large amount of ascites from the peritoneal to the pleural cavity through diaphragmatic defects. Methods The study included 120 patients admitted with hepatic cirrhosis, who presented unilateral or bilateral pleural effusion in 24 % of cases, in absence of ascites.In order to evaluate pleural affection and establish etiology, chest radiography was performed on all patients; in patients with pleural interest, pleural fluid was evaluated biochemically and, in certain cases, pleural biopsy, pulmonary CT-scan, and pulmonary MRI were also performed. Results The etiology of hepatic cirrhosis in our group was mainly from C virus, followed by the alcohol consuming. The pleural fluid localization was mainly in the right hemithorax (70%). Of the 120 patients, pleural fluid was also associated with ascites fluid in 92 de cases (76.6%), while ascites was absent in 28 cases (23.4%). In 102 cases (85%), the transudative biochemical and cytological characteristics of pleural fluid were similar to those of ascites fluid. In 10 cases (8.3%), pleural fluid was exudative and exploratory paracentesis showed transudative ascites fluid. In all 10 cases, pleural fluid was localized in the lower third of the left hemithorax. The macroscopic aspect of pleural fluid was serosanguinolent. Bacillary history, radiologic imaging, macroscopic aspect, as well as biochemical and cytology exam of pleural fluid suggested bacillary etiology, which was subsequently confirmed by favorable evolution under tuberculostatic therapy. Both pleural and ascites fluids were exudative in only 8 cases (6.7%); localization was at the base of the left hemithorax in 5 cases and bilateral in 3 cases. Abdominal echography, axial CT-scan with contrast medium, and tumoral markers confirmed the diagnosis of hepatocellular carcinoma. Conclusions Spontaneous hydrothorax is a complication of hepatic cirrhosis that occurs independently of disease etiology or ascites fluid quantity; it may also occur in absence of ascites. In 70 % of pleural effusion cases, pleural fluid is located on the right side, in absence of primary pulmonary, pleural, or cardiac complaints. Left-sided pleural fluid may suggest presence of tuberculosis or neoplasm. Efficient therapy of spontaneous cirrhotic hydrothorax depends on the treatment of ascites and consists of low-sodium diet, diuretic therapy, and recurrent paracenteses.