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Acute tension hydrothorax in chronic liver disease secondary to spontaneous diaphragmatic rupture. Pleural effusion in liver cirrhotics is more commonly transudative. A transudative pleural effusion secondary to ascites in decompensated cirrhosis is also known as hepatic hydrothorax and is usually due to fluid seepage through congenital pores in the diaphragm. The patient, a known case of decompensated chronic liver disease, presented with a massive, left-sided, rapidly accumulating and transudative pleural effusion secondary to spontaneous diaphragmatic rupture. Clinically, he developed sudden onset shortness of breath and became hypotensive. This is a rare entity, and was confirmed on CT thorax revealing a focal segment defect ~1.6 cm over the left hemidiaphragm. Ascites treatment consisting of diuretics with salt restriction and repeated thoracentesis with albumin replacement improved his symptoms and lead to a complete resolution of the effusion.