Diagnosis of isolated hepatic hydrothorax using peritoneal scintigraphy

Hepatic hydrothorax (HHT), a pleural effusion in patients with end-stage liver disease, is typically found in patients with ascites, presumably attributed to migration of ascitic fluid across defects in the diaphragm. The diagnosis is a clinical diagnosis, typically made in patients with cirrhosis, portal hypertension, ascites, and a transudative pleural effusion. Although uncommon, HHT can occur even in patients with minimal or no apparent ascites, perhaps attributed to intra-abdominal pressure greater than pleural pressure, creating a caudal gradient. However, a lack of ascites can make the diagnosis challenging. An excellent diagnostic approach is to confirm the diagnosis by use of peritoneal scintigraphy, but is exceptionally challenging in patients without ascites. Here, we report on the experience with a patient in which we used intraperitoneal saline infusion before peritoneal scintigraphy to demonstrate flow of fluid from the peritoneal to the chest cavity and confirm the diagnosis of HHT.