Hepatic hydrothorax is defined as significant pleural effusion (usually greater than 500 mL) in a cirrhotic patient, in the absence of underlying pulmonary or cardiac disease. The diagnosis of hepatic hydrothorax should be suspected in a patient with established cirrhosis and portal hypertension, presenting with unilateral pleural effusion, most commonly right-sided. Hydrothorax is uncommon, and is found in 4-6% of all patients with cirrhosis and up to 10% in patients with decompensated cirrhosis. Although ascites is usually present, hydrothorax can occur in the absence of ascites. Patients with hepatic hydrothorax usually have advanced liver disease with portal hypertension and most of them require liver transplantation. Current insight into the pathogenesis of this entity has led to improved treatment modalities such as portosystemic shunts (TIPS) and video-assisted thoracoscopy for closure of diaphragmatic defects. These modalities may provide a bridge towards transplantation.