A 62-year-old male presented to the emergency room with dyspnea and right upper abdominal pain for two days. He denied any trauma history. His medical history was significant for cirrhosis Child-Pugh A, chronic hepatitis B and a hepatocellular carcinoma measuring 3.3 cm in segment VII. Radiofrequency ablation (RFA) had been performed 12 months ago. On arrival, his blood pressure was 76/37 mmHg, heart rate was 110 beats per minute, oxygen saturation was 88% and temperature was 36.8 degree Celsius. On physical examination, there was tenderness over the right upper quadrant region, breathing sounds of the right lung were diminished and extremities were cold and clammy. Initial resuscitation was done. Plain radiograph revealed right pleural effusion (figure 1a).