Hepatic hydrothorax: a comprehensive approach to diagnosis and management

Background: Hepatic hydrothorax (HH) is an uncommon but serious complication of advanced cirrhosis, characterized by transudative pleural effusion in the absence of cardiopulmonary or renal pathology. Despite its relatively low prevalence, HH carries significant morbidity and mortality, often presenting complex diagnostic and therapeutic challenges. Summary: The pathogenesis of HH is multifactorial, primarily involving the passage of ascitic fluid through diaphragmatic defects, exacerbated by altered hemodynamics, hypoalbuminemia, and neurohormonal dysregulation. Diagnosis relies on identifying transudative pleural effusion and excluding alternative etiologies. Management requires a stepwise multidisciplinary approach. Initial therapy includes sodium restriction, diuretics, and paracentesis to control ascites. Refractory cases may require serial thoracenteses, transjugular intrahepatic portosystemic shunt (TIPS) or surgical interventions in selected cases. Liver transplantation remains the definitive treatment leading to survival outcomes comparable to other transplant indications. Conclusion: HH develops in advanced cirrhosis and predicts a poor prognosis, with median survival often less than one year without transplantation. Optimal care requires early recognition, individualized treatment planning, and close multidisciplinary coordination between hepatology, pulmonology, interventional radiology, and surgical teams. Further research is needed to refine risk stratification and establish standardized management algorithms to improve patient outcomes.