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The incidence of hydrothorax varies between 1.6-10% of PD patients, with females predominating. The right side is more commonly affected than the left. Polycystic kidney disease is a predisposing factor. Congenital causes include the localized absence of muscle fibers or tendinous diaphragmatic defects and eventration. Among the acquired etiologies are trauma to the abdomen and other causes of increased intra-abdominal pressure. A one-way passage of fluid between the peritoneal and pleural cavities is occasionally observed with valve-like defects of the diaphragm or hepatic capsule tamponade.
Diagnosis. Hydrothorax can be asymptomatic in about 25% of patients and is diagnosed as an incidental finding on routine physical examination. The most common symptom and sign are dyspnea and inadequate ultrafiltration capacity. A post infusion chest x-ray followed by a second simple chest x-ray after draining the peritoneal cavity is the simplest way of confirming the diagnosis. Isotope peritoneo-pleurograms with radioisotopes or peritoneography with contrast media can provide better definition of the diaphragmatic defect. In the absence of definite evidence of a pleural-peritoneal communication, a pleural fluid sample can confirm the diagnosis by the presence of a higher glucose concentration than plasma, the LDH and protein concentrations of a transudate and the presence of d-isomers of lactate.
Pleuro-peritoneal leak
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Diagnosis of pleuro-peritoneal leak (hydrothorax) with scintigraphy. The left panel shows the patient in the standing position and minimal effusion above the diaphragm. The right panel shows the accumulation of fluid above the diaphragm when the patient assumed the supine position.
Treatment. Acute thoracentesis is seldom required for treatment of an acute and severe presentation of a hydrothorax with respiratory compromise. The simple drainage of the peritoneal cavity and avoidance of overnight dwells in the supine position can correct the problem in some patients. The persistence of hydrothorax requires permanent obliteration of the pleuro-peritoneal communication with pleurodesis using autologous blood, talc, tetracycline, surgical or thoracoscopic correction or video-assisted thoracoscopic (VATS) talc pleurodesis.
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