Hepatic Hydrothorax

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Top tips:

  1. Consider non hepatic causes in the differential diagnosis of a pleural effusion in a patient with cirrhosis
  2. The mainstay of therapy for a hepatic hydrothorax is sodium restriction and diuretics.
  3. In symptomatic patients pleural fluid drainage is suggested.  Although there are varying protocols for carrying out drainage, a conservative guidance is to drain a maximum of 1.5 L of pleural fluid over 6hours to avoid re-expansion pulmonary edema.
  4. Do not use surgical chest tube placement
  5. Consider candidacy for a Transjugular Intrahepatic Portosystemic Shunt (TIPS)
  6. Consider candidacy for liver transplantation

Order panels for Hepatic Hydrothorax and Thoracentesis:

For adults with cirrhosis admitted with Hepatic Hydrothorax.
Ascites Hepatic Hydrothorax, Edema in Cirrhosis Order

For adult inpatients with cirrhosis requiring thoracentesis.
Inpatient Thoracentesis Order Panel

General Cirrhosis Admission and Discharge Order Sets

*Add specific panels to general admission orders as appropriate*

For adults with cirrhosis requiring hospital admission
Cirrhosis Adult Admission Orders

For adults with cirrhosis requiring hospital discharge
Cirrhosis Adult Discharge Orders

Dr. Li cartoon
Dr. Tandon cartoon 1
Dr. Abraldes cartoon-needs white hair

Thank you to Dr. Li, Dr. Tandon, and Dr. Abraldes for your efforts creating the content on this page. Check out the bottom of the page for short videos from Dr. Li and Dr. Abraldes!


General Management

Specific Management

Substituting Spironolactone with Amiloride

Amiloride has a weaker diuretic effect but can be substituted for Spironolactone if painful gynecomastia becomes a problem.

Starting dose of 10mg

where 10mg = 100mg of Spironolactone

Maximum dose of 40mg of Amiloride. 

More information on Spironolactone & Furosemide

A ratio of 50-100mg Spironolactone to 20-40mg Furosemide often works to balance the electrolytes, but must be individualized.

The ratio of diuretics can be adjusted to control hyperkalemia (i.e., if hyperkalemia is present, reduce Spironolactone).

If the electrolytes and creatinine are ok, doses can be increased in increments of 50mg Spironolactone to 20mg Furosemide.

For example, starting doses of Spironolactone 50mg and Furosemide 20mg can go to 100mg and 40mg respectively after 4-7 days.

See more information on using the urine sodium

#1: Dietary non-compliance - Spot urine Na/K ratio is >1 OR the 24-hour urine Na excretion is >78 mEq/day in a patient on diuretics who is not losing weight This means the patient is sensitive to diuretics but not adherent to sodium restriction.
#2: Diuretic resistance - Spot urine Na/K ratio is ≤1 OR 24-hour urinary Na excretion is <78 mEq per day in a patient on maximally tolerated diuretics who is not losing weight. This means the patient is resistant to diuretics

Introducing Dr. Tandon, Dr. Li and Dr. Abraldes

Video 1 – Practical tips for carrying out a thoracentesis safely, what to send the fluid for and when to think of an alternate cause for the fluid than cirrhosis!

Video 2 - Transjugular intrahepatic portosystemic shunt (TIPS) for a patient with cirrhosis and a hydrothorax or ascites – indications and cautions.

Video 3 – Indwelling pleural catheters for a patient with cirrhosis and a hydrothorax – indications and cautions.

Patient materials:

You can direct patients to the following:

Pleural effusion


Light’s criteria:

Light’s criteria calculator


This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors: Dr. Marilyn Zeman, Dr. Pen Li, Dr. Vijey Selvarajah, Dr. Brian Buchanan, Dr. Puneeta Tandon


  1. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
  2. Advancing Liver Therapeutic Approaches (ALTA) Consortium (2022). North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association20(8), 1636–1662.e36. https://doi.org/10.1016/j.cgh.2021.07.018 PMID 34274511

Last reviewed November 3, 2022

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