Hepatic hydrothorax (HH) is an uncommon complication in patients with end-stage liver disease. Only 5% to 10% of patients with end-stage liver disease develop HH, which may result in dyspnea, hypoxia, and infection, and portends a poor prognosis. The most likely explanation for development is passage of fluid from the peritoneal space to the pleural space due to small diaphragmatic defects. Initial management consists of diuretics with dietary sodium restriction and thoracentesis, and a transjugular intrahepatic portosystemic shunt may ultimately be required. Afflicted patients can develop morbid and fatal complications, pose management dilemmas, and should warrant evaluation for liver transplantation.