Hepatic hydrothorax in the management of cirrhosis

We thank Aithal et al 1 for their recent guidelines on the management of ascites in cirrhosis. We lead a pleural service in the North East of England and frequently deal with hepatic hydrothoraces (HH). We believe that the guidelines will be significantly enhanced by mentioning some figures around HH and the management so that clinicians and patients are better informed. HH is predominantly right-sided due to diaphragmatic defects, but up to 17.5% of effusions are left and 3% bilateral. Of patients 21%–26% develop refractory HH.2 As a first-line intervention, thoracocentesis has a low complication rate (pneumothorax 0.6%–6% and haemothorax 0%–2%). Shojaee et al 3 performed a case–control study of 82 patients with HH undergoing 274 thoracenteses and 100 control patients undergoing 188 thoracenteses. The complication rate was higher with repeat thoracocentesis in patients with HH (8% vs 0%, p=0.016, 95% CI …