Purpose of the Review <p>To review epidemiology, pathogenesis, diagnosis, and management of hepatic hydrothorax.</p> Recent Findings <p>Refractory hepatic hydrothorax is an independent predictor of mortality in patients with decompensated cirrhosis. Allocation of Model for End-Stage Liver Disease exception points for patients with refractory hydrothorax was found to be associated with a significant reduction in post liver transplant mortality.</p> Summary <p>Hepatic hydrothorax, pleural effusion in patients with decompensated liver cirrhosis without primary pleural and cardiopulmonary pathology is associated with a high rate of morbidity and mortality. Pathogenesis is a combination of salt and water retention and unidirectional movement of fluid from the peritoneal to the thoracic cavity. Diagnosis relies on pleural fluid analysis and ruling out a primary pleural and cardiopulmonary pathology. Management is complex and requires a stepwise and multidisciplinary approach. All patients with refractory hydrothorax should be evaluated for liver transplant.</p>