Cilia BJ, Haridy J, Raj A, Hannah N. Hepatic hydrothorax as a manifestation of decompensated cirrhosis: An update on current management and future directions. World J Hepatol 2025; 17(10): 110412 [PMID: 41179726 DOI: 10.4254/wjh.v17.i10.110412]
Corresponding Author of This Article
Nicholas Hannah, MD, Consultant, FRACP, Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Melbourne 3050, Victoria, Australia. nicholas.hannah2@mh.org.au
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Gastroenterology & Hepatology
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Minireviews
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Oct 27, 2025 (publication date) through Dec 11, 2025
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World Journal of Hepatology
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1948-5182
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Cilia BJ, Haridy J, Raj A, Hannah N. Hepatic hydrothorax as a manifestation of decompensated cirrhosis: An update on current management and future directions. World J Hepatol 2025; 17(10): 110412 [PMID: 41179726 DOI: 10.4254/wjh.v17.i10.110412]
World J Hepatol. Oct 27, 2025; 17(10): 110412 Published online Oct 27, 2025. doi: 10.4254/wjh.v17.i10.110412
Hepatic hydrothorax as a manifestation of decompensated cirrhosis: An update on current management and future directions
Brandon-Joe Cilia, James Haridy, Ashok Raj, Nicholas Hannah
Brandon-Joe Cilia, Nicholas Hannah, Faculty of Medicine, Dentistry and Health Sciences, Melbourne Medical School, University of Melbourne, Melbourne 3010, Victoria, Australia
Brandon-Joe Cilia, James Haridy, Ashok Raj, Nicholas Hannah, Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne Health, Melbourne 3050, Victoria, Australia
Nicholas Hannah, Department of Gastroenterology, Northern Health, Melbourne 3076, Victoria, Australia
Nicholas Hannah, Department of Gastroenterology, Western Health, Melbourne 3011, Victoria, Australia
Author contributions: Cilia BJ performed manuscript writing and revision, and prepared the figures and table; Haridy J and Raj A contributed to critical revision of the paper; Hannah N designed the outline and coordinated the writing of the paper; all authors approved the final version of the manuscript.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nicholas Hannah, MD, Consultant, FRACP, Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Melbourne 3050, Victoria, Australia. nicholas.hannah2@mh.org.au
Received: June 6, 2025 Revised: July 3, 2025 Accepted: September 24, 2025 Published online: October 27, 2025 Processing time: 143 Days and 23.1 Hours
Abstract
Hepatic hydrothorax (HH) is an uncommon yet severe manifestation of portal hypertension which develops in 5%-10% of patients with liver cirrhosis. It typically presents as a unilateral, right-sided pleural effusion and in the context of end-stage liver disease and concomitant ascites. The most widely accepted explanatory model for HH accumulation is the formation of small diaphragmatic defects (pleuroperitoneal connections) facilitating migration of ascitic fluid from the peritoneal cavity directly to the pleural cavity. Medical management involves sodium restriction and diuretic therapy, with thoracentesis also offering symptomatic relief. In cases of refractory HH, a transjugular intrahepatic portosystemic shunt is considered either as definitive treatment or as a bridge to liver transplantation, which remains the only curative treatment option. HH refractory to medical therapy presents a challenging clinical dilemma, particularly in those who are ineligible for liver transplantation. In this mini-review, we aim to highlight the pathophysiology, clinical presentation, diagnosis and management of HH. Additionally, we discuss and appraise novel therapeutic options and offer future directions.
Core Tip: Hepatic hydrothorax (HH) commonly presents as a right-sided pleural effusion in patients with cirrhosis after excluding cardiopulmonary and renal causes. The most widely accepted mechanism is migration of ascitic fluid via small diaphragmatic defects directly into the pleural space. Medical management is centred around sodium restriction and diuretics, with thoracentesis also offering symptomatic relief. A transjugular intrahepatic portosystemic shunt (TIPS) is generally first line when HH becomes refractory to medical therapy. Beyond TIPS and liver transplantation, there are few alternatives for those who are ineligible. However, promising modalities such as indwelling pleural catheters, albumin infusions, and continuous terlipressin require further validation.
