Dynamic Evolution of Pleural Effusion: Hepatic Chylothorax Transforming Into Hydrothorax With Trapped Lung in Advanced Cirrhosis
Document Type
Conference Proceeding
Publication Date
5-2025
Publication Title
American Journal of Respiratory and Critical Care Medicine
Abstract
Chylothorax is a rare complication in cirrhosis, seen in only 1% of cases, typically due to thoracic duct disruptions caused by elevated venous and lymphatic pressures from cirrhosis-induced portal hypertension. In contrast, hepatic hydrothorax affects 5-10% of cirrhotic patients and involves the translocation of ascitic fluid into the pleural space through diaphragmatic defects. The shift from chylothorax to hepatic hydrothorax in cirrhosis is a rare clinical occurrence, requiring a deeper understanding of the evolving fluid dynamics and complex pathophysiology involved. A 69-year-old male with NASH cirrhosis, HFrEF, and recurrent ascites who presented with worsening dyspnea and abdominal distension. He had experienced a 50-pound unintentional weight loss over six months due to poor appetite and required paracentesis every 1-2 weeks for refractory ascites. Upon admission, imaging revealed a large right-sided pleural effusion. Diagnostic thoracentesis drained 2 liters of yellow, milky fluid, which showed elevated triglycerides (153 mg/dL) and low cholesterol (15 mg/dL), consistent with chylothorax. Lymphangiography identified a small thoracic duct leak near the diaphragm. Despite thoracic duct embolization, the effusion persisted, with chest tube drainage of 3-4 liters daily, and intermittent clamping was required to manage hypotensive episodes. Over time, repeat pleural fluid analysis revealed decreasing triglycerides (59 mg/dL), increasing protein (2.0 g/dL), and elevated LDH (134 U/L), suggesting a shift towards a transudative hepatic hydrothorax. Repeated invasive interventions led to secondary infections with Staphylococcus lugdunensis and Staphylococcus auricularis, causing fibrinous pleuritis and limiting therapeutic options like long-term PleurX catheter placement. The patient underwent VATS with partial decortication and pleurodesis. Multiple loculated collections and a trapped right lung limited pleurodesis success. Tailored antibiotic therapy was administered based on culture results, initially using vancomycin and later transitioning to Bactrim. This case highlights the evolving nature of pleural effusions in cirrhotic patients, transitioning from chylothorax to hepatic hydrothorax. Chylothorax was diagnosed by elevated triglycerides and milky pleural fluid, confirmed by a lymphangiogram showing a thoracic duct leak likely due to portal hypertension. Despite thoracic duct embolization, persistent effusions indicated ongoing fluid accumulation driven by high portal pressures. As fluid analysis showed declining triglycerides and increased protein, the effusion shifted towards hepatic hydrothorax. Repeated interventions led to infections with Staphylococcus species, causing fibrinous pleuritis and a trapped lung. The patient underwent VATS with partial decortication, but ongoing infection and lung entrapment precluded long-term catheter placement. This case underscores the need for careful monitoring and adaptive management in complex cirrhotic patients.
Volume
211
First Page
A6258
Last Page
A6258
Recommended Citation
Bin Hameed U, Amal T, Nazneen W, Moazzam M. Dynamic evolution of pleural effusion: hepatic chylothorax transforming into hydrothorax with trapped lung in advanced cirrhosis. Am J Respir Crit Care Med. 2025 May;211:A6258. doi:10.1164/ajrccm.2025.211.Abstracts.A6258
DOI
10.1164/ajrccm.2025.211.Abstracts.A6258
Comments
American Thoracic Society (ATS) International Conference, May 16-21, 2025, Sand Francisco, CA