A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension

OBJECTIVES

Hepatopulmonary syndrome consists of a triad of hepatic dysfunction and/or portal hypertension, intrapulmonary vascular dilatations and hypoxemia. A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension was undertaken.

METHODS

Thirty patients participated in this study. The diagnosis of cirrhosis of liver was confirmed by liver biopsy. Arterial blood gas analysis, pulmonary function tests, two-dimensional transthoracic air contrast echocardiography were undertaken in all the patients. Those patients in whom contrast echocardiogram showed intrapulmonary vascular dilatations were classified as the positive group while others were labelled as the negative group.

RESULTS

Ten patients (33.33%) had a positive contrast echocardiogram; five (16.67%) of them were found to have PaO2<70 mmHg and were qualified for the diagnosis of hepatopulmonary syndrome (HPS); and other five (16.67%) with PaO2>70 mmHg were diagnosed as intrapulmonary dilatations syndrome (IPVDS). Five patients of HPS revealed significant P(A-a)O2 gradient and intrapulmonary shunts of moderate severity computed by a/A ratio. Cyanosis (p=0.001), clubbing (p=0.009) and orthodeoxia (p=0.0024) were significantly commoner in the five patients of hepatopulmonary syndrome. Presence of spider naevi was significantly related with the presence of intrapulmonary vascular dilatations.

CONCLUSIONS

The study results showed presence of hepatopulmonary syndrome and intrapulmonary vascular dilatation syndrome among patients of portal hypertension. The presence of cyanosis, clubbing and orthodeoxia were found to be suggestive indicators of hepatopulmonary syndrome. Even though not very specific, spider naevi were found to be a useful clinical indicator for the presence of intrapulmonary vascular dilatations.

Hepatopulmonary syndrome. A review of the literature

The majority of cirrhotic patients present dyspnea, but most of the time this is a consequence of ascites, hepatic hydrothorax or cardiopulmonary disease. Very few of these patients undergo the hepatopulmonary syndrome, an infrequent complication of chronic liver disease, especially when associated with portal hypertension and cirrhosis. Hepatopulmonary syndrome is characterised by dyspnea and, consequently, arterial hypoxemia, due to intrapulmonary vasodilation and shunting. The real pathogenesis of this vasodilation is still unknown, although many hypotheses have been suggested. Furthermore, no medical therapy appears to be really useful in the treatment of hepatopulmonary syndrome. At the present time, the only treatment that is efficacious for the resolution, or for the improvement of blood gas oxygenation abnormalities, is orthotopic liver transplantation.

Hepatopulmonary syndrome and portopulmonary hypertension

Liver disease affects the lungs. The majority of patients exhibit mild to moderate arterial hypoxaemia essentially attributable to an alteration in ventilation/perfusion matching and limited by an increase in ventilation. A minority (some 10%) of patients exhibit a "hepatopulmonary syndrome" defined by severe hypoxaemia with arterial PO2 below 60 mm Hg, dyspnoea, cyanosis, digital clubbing, orthodeoxia, platypnoea and demonstrable pulmonary vascular dilatations causing a true pulmonary shunt and a diffusion/perfusion imbalance. The hepatopulmonary syndrome is incurable but resolves over time after liver transplantation. An even lower proportion of patients, approximately 1%, develop pulmonary hypertension. Clinically this "portopulmonary hypertension" resembles primary pulmonary hypertension, with dyspnoea and fatigue as the main symptoms, histopathology and response to prostacyclin therapy. Portopulmonary hypertension is irreversible. Liver transplantation mortality in patients with portopulmonary hypertension ranges from 50 to 100%. The common cause of the hepatopulmonary syndrome and portopulmonary hypertension is portal hypertension and portosystemic shunting, indicating that vasoactive and angiogenetic factors originating from the liver normally control the pulmonary circulation.

Hepatopulmonary syndrome in a child

We report a case of congenital biliary atresia and liver cirrhosis who developed hepatopulmonary syndrome thirteen years after Kasai operation. This 15-yea-old girl suffered from hyperbilirubinemia and acholic stool since birth. Congenital biliary atresia was diagnosed at 6 weeks of age and she received Kasai operation when liver cirrhosis was also found during the surgery. Dyspnea and cyanosis insidiously occurred since the age of 13 and she had been admitted to our hospital due to episodes of esophageal varices bleeding where esophageal varices ligation was performed. Serial examinations showed PaO2: 71 mmHg despite of 100% oxygen supplement. Pulmonary catheterization showed multiple arteriovenous shunts and macroaggregated albumin test revealed significant shunting. Contrast-enhanced echocardiogram showed microbubbles in the left heart. Thus, hepatopulmonary syndrome type II was diagnosed. Treatment is a dilemma although liver transplantation with concomitant lung transplantation is a possible choice.

Prospective evaluation of outcomes and predictors of mortality in patients with hepatopulmonary syndrome undergoing liver transplantation

The hepatopulmonary syndrome (HPS) occurs in a subgroup of patients with cirrhosis and results from intrapulmonary vasodilatation, which may cause significant hypoxemia. Liver transplantation has emerged as a therapeutic option for patients with HPS based on retrospective case series and reports. However, morbidity and mortality appear to be increased after transplantation for HPS, and no prospective studies evaluating clinical features that may predict poor surgical outcome are available. Therefore, we prospectively evaluated the utility of the degree of hypoxemia, the arterial oxygen response to 100% oxygen administration, and the macroaggregated albumin (MAA) scan quantification of intrapulmonary shunting as predictors for outcome after liver transplantation. Our cohort consisted of 24 patients with cirrhosis and HPS who underwent liver transplantation over a 5-year period at 2 transplant centers who were followed at least 1 year after transplantation. All patients underwent preoperative evaluation for HPS with standardized methods. Seven patients (29%) died postoperatively, 5 of cardiorespiratory complications. All deaths occurred within 10 weeks after transplantation. A preoperative arterial oxygen tension (PaO(2)) of </= 50 mm Hg alone or in combination with a MAA shunt fraction >/= 20% were the strongest predictors of postoperative mortality. In conclusion, we found that mortality is increased after liver transplantation for HPS, particularly in patients with more severe hypoxemia and significant intrapulmonary shunting. Preoperative testing for the severity of HPS can be used to stratify patients according to the risk for postoperative mortality.

[Hepatopulmonary syndrome]

Liver diseases affect lungs. Pulmonary vascular diseases are observed in hepatic diseases and portal hypertension have a wide spectrum that varies from intrapulmonary vascular dilatation to increased pulmonary vascular resistance with pulmonary hypertension. Hepatopulmonary syndrome is a syndrome characterized portal hypertension, intrapulmonary vascular dilatation and abnormal oxygenation (hypoxaemia). This review summarizes the clinicopathologic features, diagnostic criteria, and management of hepatopulmonary syndrome.

Hepatopulmonary syndrome: prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences

BACKGROUND

The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and pulmonary vascular dilatation. The reported prevalence of HPS in cirrhotic patients varies between 4% and 19%, and various threshold values defining arterial deoxygenation have been used and recommended previously. However, it is not known how the prevalence of HPS differs using different cut off values for arterial deoxygenation.

METHODS

We studied 127 patients for the presence of HPS using transthoracic contrast echocardiography for detection of pulmonary vasodilation, pulmonary function tests, and blood gas analysis.

RESULTS

Ninety eight patients were included in the study, of whom 33 (34%) had a positive contrast echocardiography. Using an increased alveolar-arterial difference for the partial pressure of oxygen (AaDO(2)) as an indication of hypoxaemia, the prevalence of HPS was considerably higher (>15 mm Hg, 32%; >20 mm Hg, 31%; and >age related threshold, 28%) than using reduced partial pressure of arterial oxygen (PaO(2)) as a threshold (<80 mm Hg, 19%; <70 mm Hg, 15%; and <age related threshold, 15%). For AaDO(2) as the cut off, the positive predictive value for a diagnosis of HPS was low (34%, 37%, and 53%, respectively). In contrast, PaO(2) as a cut off had considerably higher positive predictive values (44%, 93%, and 94%, respectively). Introducing PaO(2) <65 mm Hg as the cut off, the positive predictive value increased to 100%. Dyspnoea was more often present in patients with "clinically significant" HPS (57%) compared with "subclinical HPS" (8%), and patients without HPS (6%). The Child-Pugh score correlated significantly with the severity of HPS. Two of five liver transplanted patients with "subclinical HPS" had embolic brain infarcts, possibly induced by venous emboli passing through dilated intrapulmonary vessels.

CONCLUSIONS

Defining arterial hypoxaemia in HPS by different, previously used, cut off values for arterial oxygenation leads to a wide variation in the prevalence of HPS in the same sample of cirrhotic patients.

Abernethy malformation: one of the etiologies of hepatopulmonary syndrome

Hepatopulmonary syndrome (HPS) is the clinical relationship between hepatic disease and the existence of pulmonary vascular dilatations, which can result in a range of arterial oxygenation abnormalities. It is probably caused by an alteration in the synthesis or metabolism of vasoactive pulmonary substances at a hepatic level, leading to vasodilatation of pulmonary vessels and diffusion perfusion defects. The Abernethy malformation is characterized by the congenital diversion of portal blood away from the liver, by either end-to-side or side-to-side shunt. Here, we report on a 5-year-and-11-month-old-boy who had started cyanosis at age 4 years and 11 months, and did not have any other pulmonary or cardiac signs or symptoms. In the investigation, arterial blood gases revealed a PaO(2) of 41.4 mm Hg. The chest x-ray film and echo Doppler cardiography were normal. Nuclear scanning with Technetium 99m-labeled macroaggregated albumin showed the presence of arteriovenous shunt, at 47%. Abdominal echography revealed Abernethy malformation with an absence of portal vein. We concluded that the patient had HPS caused by Abernethy malformation. The possible mechanism is that in this malformation, there is a deviation in the blood that comes from the spleen to the vena cava without passing through the liver, so there is no metabolism of some substances which can be responsible for the imbalance between the vasodilatation and the vasoconstriction of the pulmonary circulation. Abernethy malformation must be included as one of the etiologies of hepatopulmonary syndrome. This is the first case described in the literature with this form of presentation.

Hepatopulmonary syndrome: a case report

The Hepatopulmonary Syndrome (HPS) is one of many extrahepatic manifestations of liver failure. It consists of a triad of liver dysfunction, intrapulmonary vascular dilatation and hypoxemia. We present a case of post necrotic cirrhosis (HBV related) who developed exertional dyspnoea subsequent to the development of hepatopulmonary syndrome.

[Significance of lung perfusion scanning with technetium labeled macroaggregated albumin and pulmonary function assay for diagnosis of early hepatopulmonary syndrome]

OBJECTIVE

To evaluate the values of pulmonary function assay and dynamic pulmonary perfusion imaging with technetium labeled macroaggregated albumin ((99m)TcMAA) in the early diagnosis of hepatopulmonary syndrome (HPS).

METHODS

The pulmonary function assay and (99m)TcMAA scans were performed in 28 patients with HPS, 30 cirrhotic patients (CP) without HPS, and 21 healthy controls (HC).

RESULTS

In the patients with HPS, PaO(2), SaO(2) and diffusion capacity for carbon monoxide of lungs (DLco) was significantly lower than that in CP (P<0.01) and HC (P<0.01), and alveolar-arterial gradient [P((A-a))O(2)] was significantly increased (P<0.001). Results from (99m)TcMAA scans showed that the radionuclides were distributed over the spleen, kidney, liver and brain, and the ratios of arterivenous shunt were significantly higher than that in CP (P<0.001) and NC (P<0.001). In cirrhotic patients, DLco significantly decreased (P<0.05), P((A-a))O(2) and shunt ratios increased (P<0.01 and 0.001).

CONCLUSIONS

Pulmonary function assay and dynamic pulmonary perfusion imaging with (99m)TcMAA are sensitive methods for diagnosis of the early HPS.

Hepatopulmonary syndrome in poorly compensated postnecrotic liver cirrhosis by hepatitis B virus in Korea

BACKGROUND

Hepatopulmonary syndrome (HPS) refers to the association of hypoxemia, intrapulmonary shunting and chronic liver disease. But there is no clear data about the prevalence of HPS in postnecrotic liver cirrhosis by hepatitis B virus (HBV), the most common cause of liver disease in Korea. The aim of this study was to investigate the prevalence of HPS in poorly compensated postnecrotic liver cirrhosis by HBV, and the correlation of the hepatopulmonary syndrome with clinical aspects of postnecrotic liver cirrhosis by HBV.

METHODS

Thirty-five patients underwent pulmonary function test, arterial blood gas analysis and contrast-enhanced echocardiography. All patients were diagnosed as HBV-induced Child class C liver cirrhosis and had no evidence of intrinsic cardiopulmonary disease.

RESULTS

Intrapulmonary shunt was detected in 6/35 (17.1%) by contrast-enhanced echocardiography. Two of six patients with intrahepatic shunts had significant hypoxemia (PaO2 < 70 mmHg) and four showed increased alveolar-arterial oxygen gradient over 20 mmHg. Only cyanosis could reliably distinguish between shunt positive and negative patients.

CONCLUSIONS

The prevalence of intrapulmonary shunt in poorly compensated postnecrotic liver cirrhosis by HBV was 17.1% and the frequency of hepatopulmonary syndrome was relatively low (5.7%). 'Subclinical' hepatopulmonary syndrome (echocardiographically positive intrapulmonary shunt but without profound hypoxemia) exists in 11.4% of cases with poorly compensated postnecrotic liver cirrhosis by HBV. Cyanosis is the only reliable clinical indicator of HPS of HBV-induced poorly compensated liver cirrhosis. Further studies are required to determine if the prevalence and clinical manifestations of HPS varies with etiology or with geographical and racial differences.

Novel presentation and approach to management of hepatopulmonary syndrome with use of antimicrobial agents

A 44-year-old man with hepatitis C-associated liver cirrhosis, cyanosis, digital clubbing, and platypnea presented with left-side hemiplegia found to be due to a brain abscess. Hepatopulmonary syndrome was diagnosed after demonstration of the presence of a massive intrapulmonary shunt. Although the anomalous vascular channel never was defined anatomically, follow-up studies confirmed the presence of a functional shunt. Culture of a sample from the abscess yielded Streptococcus intermedius. It was hypothesized that the patient's pulmonary vascular pathology was due, in large part, to chronic elevated levels of nitric oxide (a potent vasodilator thought to be generated by endotoxin absorbed from the gut). Treatment with oral norfloxacin was initiated on the basis of data that this antibiotic reduces endotoxemia and concomitant nitric oxide production in patients with cirrhosis. Four months after initiation of treatment, the patient's hypoxia had resolved.

Scintiscanning in diagnostics of hepatopulmonary syndrome in children

BACKGROUND

Arterial blood oxygenation disturbances accompanying liver cirrhosis are referred to as hepatopulmonary syndrome (HPS). HPS develops due to the formation of intrapulmonary arteriovenous shunts and dilatation of the vascular bed. The aim of the study was to assess the incidence of arteriovenous shunts in children with hepatic cirrhosis and HPS suspected on the basis of clinical signs, qualified for liver transplantation.

MATERIAL AND METHODS

The study was carried out in a group of 21 children aged from 1.2 to 17.7 years (mean age 8.4); 8 girls and 13 boys. The patients were diagnosed as follows: biliary cirrhosis due to extrahepatic bile duct impatency--12, post-inflammatory liver cirrhosis due to infection with HVB--2, autoimmune hepatitis--2, fibrosis of the liver--2, alpha 1-antitrypsin deficiency--1, progressive familial intrahepatic cholestasis--1, cystic fibrosis--1. The presence of arteriovenous anastomoses in the lungs was detected by scintiscanning utilizing microspheres (albumin macroaggregates). Under physiologic conditions, technetium-labeled microspheres injected i.v. are accumulated in pulmonary capillaries. Radioactivity detected in other organs (kidneys, brain) indicates the presence of pathologic shunts omitting the alveoli. A percentage ratio of radioactivity detected in the brain to that present in the lungs serves as the index of blood flow through the anastomosis (SI--shunt index). According to Grimon, the mean SI value for healthy children amounts to 0.43%, the values ranging from 1% to 2% are regarded as borderline ones, and those above 2% allow unequivocal diagnosis of HPS.

RESULTS

The SI values obtained in the study ranged from 0.06 to 51%. In 7 patients SI exceeded 1%, reaching 1.23% in one, and over 3% in the remaining 6 patients. No correlations were found either between SI value and the etiology of cirrhosis, or between the index and clinical condition of the patient assessed according to Child-Pugh scale.

CONCLUSIONS

1. Scintiscanning revealed the presence of arteriovenous shunts in the lungs of 6/21 (28.6%) investigated patients. 2. No correlation was found between the severity of HPS and the etiology and stage of the underlying disease.

Portal hypertension and hepatopulmonary syndrome in a middle-aged man with hepatitis B infection

A 55-year-old Turkish man with a history of chronic hepatitis B for 35 years, presented with incapacitating fatigue and worsening shortness of breath. He was hospitalized several times because of hepatic encephalopathy. He underwent liver transplantation for a clinical diagnosis of Child's C cirrhosis complicated by hepatopulmonary syndrome. The explanted liver, however, was not cirrhotic and demonstrated features of hepatoportal sclerosis. Although treatment for hepatoportal sclerosis is relief of portal hypertension; in rare cases such as in this patient with liver failure, liver transplantation is indicated.

[Pulmonary vascular disease]

This review article discusses three topics related to pulmonary vascular disease: 1) pulmonary vascular changes associated with portal hypertension, 2) ANCA-associated pulmonary vasculitis, and 3) Takayasu's arteritis. Hepatopulmonary syndrome and pulmonary hypertension have recently been reported as pulmonary vascular changes accompanied with portal hypertension. Endogenous vasoactive agents that reach the pulmonary circulation through porto-systemic shunt vessels are thought to contribute to these vascular changes. In ANCA-associated vasculitis, hemorrhage, interstitial pneumonitis, and nodular lesions are common manifestations in the lung. In Takayasu's arteritis, CT occasionally demonstrates mosaic attenuation owing to pulmonary arteritis and peripheral reticulolinear changes probably due to thromboembolism.

Hepatopulmonary syndrome: clinical perspectives

Hepatopulmonary syndrome consists of a triad of chronic liver disease, pulmonary gas exchange abnormalities and pulmonary vascular dilatation in the absence of detectable cardiopulmonary disease. Patients usually present with symptoms of liver disease and the clinical recognition of this condition is a challenge. Newer non-invasive tests facilitate the diagnosis. Therapeutic strategies for this condition are still dismal. Liver transplantation is a possible curative option for a subgroup of patients with hepatopulmonary syndrome.

[Hepato-pulmonary syndrome and porto-pulmonary hypertension. Nosologic features and etiopathogenic considerations]

The liver controls pulmonary vascular tone by releasing vasoactive substances. In severe liver failure, the imbalance between vasodilator and vasoconstrictive mediators may lead to alteration of the respiratory function, called as hepatopulmonary syndrome (HPS, when a significant decrease of the vascular pulmonary resistance occurs, with development of intrapulmonary vascular dilatations) and portopulmonarv hypertension (PPH, when the vasoconstrictive prevalence, with an increase of the pulmonary vascular resistances). The clinical symptoms consist of various degree of dyspnea and hypoxemia. An overt "cor pulmonale" syndrome with right-side heart failure may be present in the most severe forms of PPH. The alteration of pulmonary vascularization may be diagnosed by means of pulmonary angiography, contrast-enhanced echocardiography and perfusion lung nuclear scanning of the lungs. Both clinical syndromes respond poorly to medical treatment, the unique therapeutical possibilities being represented by orthotopic liver transplantation (or combined heart-lung-liver or lung-liver transplantation in patients with severe PPH).

[Severe chronic hypoxemia in cirrhosis]

In the course of cirrhosis, severe chronic hypoxemia (< 60 mmHg) is exceptional, it is the most often in contact with intrapulmonary vascular anomalies and necessitates complex investigations. Authors reported a case of 16-years old patient, breach of cirrhosis with underdevelopment and that presents a severe chronic respiratory insufficiency not improved by the addition of oxygen. The different practiced explorations are in favor of an hepatopulmonary syndrome secondary probably to intrapulmonary shunting.

Transient hepatopulmonary syndrome in a patient with acute hepatitis A

The hepatopulmonary syndrome is defined as the triad of liver disease, hypoxaemia and intrapulmonary vascular dilatation. This syndrome has been described in patients with liver cirrhosis, noncirrhotic portal hypertension, and fulminant hepatic failure, however, there are no previous descriptions of hepatopulmonary syndrome in patients with acute nonfulminant viral hepatitis. We report a 47-year-old, previously healthy man that presented with acute hepatitis A, and developed progressive dyspnoea, platypnoea and orthodeoxia with no evidence of parenchymal or thromboembolic lung disease. PaO2 on room air was 58 mmHg, O2 saturation was 88% and alveolar-arterial O2 gradient was 62%. During his hospitalization serum albumin level decreased to 3.1 g/dl and prothrombin time was prolonged to 16.8 s, however, he remained alert with no signs of hepatic encephalopathy. Contrast echocardiography revealed left heart chamber opacification 3-4 cardiac cycles after the opacification of the right heart chamber, consistent with hepatopulmonary syndrome. During the following days there was a gradual improvement in the patient's condition, with resolution of his dyspnoea and gradual increase of PaO2. Repeat contrast echocardiography and PaO2 determinations, 3 weeks later, were normal. On long-term follow-up the patient remained asymptomatic with normal liver function tests and normal O2 saturation. This report indicates that hepatopulmonary syndrome may be a transient manifestation of acute hepatitis A in the absence of fulminant liver failure.

Hepatopulmonary syndrome: prevalence and clinical profile

BACKGROUND

The hepatopulmonary syndrome (HPS) is defined as a triad of liver dysfunction, intrapulmonary vascular dilatations (IPVD) and arterial hypoxemia. There is paucity of Indian studies regarding the prevalence of IPVD and arterial hypoxemia particularly amongst patients with non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO), where liver dysfunction is not a feature.

METHODS

All patients with portal hypertension and esophageal varices seen at a tertiary care hospital during 1995-98 were studied. Ultrasonography of abdomen, contrast-enhanced echocardiography (CEE), arterial blood gas analysis and assessment of alveolar-arterial oxygen gradient were done.

RESULTS

Of 138 patients with portal hypertension seen during the study period, 88 fulfilled the inclusion and exclusion criteria. These included 63 with cirrhosis, 15 with NCPF and 10 with EHPVO. CEE showed IPVD in 17 (27%) patients with cirrhosis, of which 11 (17.5%) fulfilled the criteria for HPS. IPVD were also noted in 4 (26.6%) cases of NCPF and 3 (30%) of EHPVO, though only 2 (13.3%) and 1 (10%) respectively had elevated alveolar-arterial gradient and liver dysfunction in addition. Age and sex distribution and duration of symptoms were not different in patients with HPS. Patients with HPS had higher incidence of dyspnea, platypnea, clubbing and spider nevi.

CONCLUSIONS

Hepatopulmonary syndrome is present in 17.5% of cirrhotics, 13.3% of patients with NCPF and 10% with EHPVO. Patients with HPS had significantly higher incidence of dyspnea, platypnea, clubbing and spider nevi.