Hepatic hydrothorax

2° diaphragmatic defect; often unilateral, R >L, ± ascites

Treatment: avoid chest tube (↑ complications); Rx same as ascites (TIPS if refractory). Indwelling pleural catheter potential option if refractory for palliation (Chest 2019;155:307)

Spontaneous empyema can occur (even w/o SBP) → dx thoracentesis; Rx abx

Rx: Δ pressure gradient (ie, ↓ ascitic fluid volume, NIPPV)

avoid chest tubes; prn thoracenteses, pleurodesis, TIPS or VATS closure of diaphragmatic defects if medical Rx fails; NIPPV for acute short-term management

spontaneous bacterial empyema (SBEM) can occur (even w/o SBP being present), ∴ thoracentesis if suspect infection

transplant is definitive treatment and workup should begin immediately