Pathogenesis and Treatment of Hydrothorax Complicating Cirrhosis with Ascites

Abstract

Eighteen cases of hydrothorax were seen among 330 consecutive hospital admissions for cirrhosis and ascites. Twenty-four hours following thoracentesis and the injection of I131 -albumin into the ascites of 9 patients, a gradient of specific activity from reformed pleural fluid to plasma in 8 patients, and additionally to thoracic duct lymph in 4 patients, indicated that the ascites was forming the hydrothroax directly across the diaphragm. The presence of a diaphragmatic defect was confirmed by the development of a pneumothorax on the side of the hydrothorax following induction of a pneumoperitoneum in 5 patients. Three patients underwent thoracoscopy, and following pneumoperitoneum in 1 air bubbles were seen coming thorugh an otherwise undetectable diaphragmatic defect. A subsequent post mortem examination revealed an opening of 1 mm in diameter in the tendinous portion of the diaphragm of this patient. Post-mortem examination in another patient revealed a 0.6 cm fluid-filled meso-thelial lined bleb on the pleural surface of the diaphragm with a microscopic defect at its base opening into the peritoneal cavity. It was concluded that the hydrothorax complicating cirrhosis is generated from ascites through such defects acquired as a result of increased intra-abdominal pressure. Treatment is directed toward eliminating the ascites by the use of diuretic agents and dietary Na restriction.