Hepatic Hydrothorax

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

For adult outpatients with cirrhosis requiring thoracentesis.
Outpatient 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

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Check out the bottom of the page for short videos from Dr. Li, Dr. Tandon and Dr. Abraldes!

Diagnosis

General Management

Specific Management

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

Video 1 – The top general tips that may be useful for you to know about this page as a family physician including: Resources to assist with a low sodium diet ; Which medications you should consider holding ; Tips about starting and adjusting diuretics.

Coming soon!

Video 2 – 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 3 - Transjugular intrahepatic portosystemic shunt (TIPS) for a patient with cirrhosis and a hydrothorax or ascites – indications and cautions.

Video 4 – Indwelling pleural catheters for a patient with cirrhosis and a hydrothorax – indications and cautions.

Patient materials:

You can direct patients to the following:
Thoracentesis

Pleural effusion

Calculators:

Light’s criteria:

Light’s criteria calculator

References:

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

References:

  1. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
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