Hepatic hydrothorax is a rare complication that occurs in patients with liver cirrhosis. We report the case of a patient with NASH cirrhosis and evidence of portal hypertension who was admitted to the emergency department with coughing and chest pain. Transudative pleural effusions (according to Light's criteria) were found in association with ascites, but no cardiac cause, pleural effusion or pulmonary effusion could be found. Treatment with diuretics was begun, but was suspended because the patient developed signifi cant renal dys- function. Fluid was drained with a thoracostomy but additional loss of fl uid led to further deterioration of renal function. It was decided to insert a transjugular portosystemic shunt (TIPS) to signifi cantly decrease portal pressure and to progressively decrease ascitic fl uid and pleural effusion. A subsequent review of the patient and radiological follow-up found no recurrence of symptoms, pleural effusion or ascites.