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Puttappa A, Sheshadri K, Fabre A, Imberger G, Boylan J, Ryan S, Iqbal M, Conlon N. Prolonged Unexplained Hypoxemia as Initial Presentation of Cirrhosis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1-6. [PMID: 28042141 PMCID: PMC5221740 DOI: 10.12659/ajcr.900530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patient: Male, 43 Final Diagnosis: Hepatopulmonary syndrome Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Anand Puttappa
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
| | - Kumaraswamy Sheshadri
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
| | - Aurelie Fabre
- Department of Histopathology, St Vincent's University Hospital, Dublin, Ireland
| | - Georgina Imberger
- Department of Anaesthesia and Pain Medicine, Western Health, Melbourne, Australia
| | - John Boylan
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
| | - Silke Ryan
- Department of Respiratory and Sleep Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Masood Iqbal
- Department of Hepatology, St Vincent's University Hospital, Dublin, Ireland
| | - Niamh Conlon
- Department of Anaesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
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Severe Hepatopulmonary Syndrome in a Child with Caroli Syndrome. Case Rep Pediatr 2017; 2017:2171974. [PMID: 28884036 PMCID: PMC5572614 DOI: 10.1155/2017/2171974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/17/2017] [Indexed: 11/20/2022] Open
Abstract
Hepatopulmonary Syndrome (HPS) is a potential complication of chronic liver disease and is more commonly seen in the adult population. Caroli Syndrome is a rare inherited disorder characterized by intrahepatic ductal dilation and liver fibrosis that leads to portal hypertension. In children with liver disease, HPS should be considered in the differential diagnosis of prolonged, otherwise unexplained, hypoxemia. The presence of HPS can improve patient priority on the liver transplantation wait list, despite their Pediatric End-Stage Liver Disease (PELD) score. We present a 6-year-old girl with Caroli Syndrome and End-Stage Renal Disease who presented with persistent hypoxemia. The goal of this report is to increase awareness of HPS in children.
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Grilo I, Pascasio JM, López-Pardo FJ, Ortega-Ruiz F, Tirado JL, Sousa JM, Rodríguez-Puras MJ, Ferrer MT, Gómez-Bravo MÁ, Grilo A. Hepatopulmonary syndrome: which blood gas analysis criteria and position should we use for diagnosis? REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS 2017; 109. [DOI: 10.17235/reed.2017.4930/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Soulaidopoulos S, Goulis I, Giannakoulas G, Panagiotidis T, Doumtsis P, Karasmani A, Oikonomou T, Tzoumari T, Karvounis H, Cholongitas Ε. Hepatopulmonary syndrome is associated with the presence of hepatocellular carcinoma in patients with decompensated cirrhosis. Ann Gastroenterol 2016; 30:225-231. [PMID: 28243044 PMCID: PMC5320036 DOI: 10.20524/aog.2016.0117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/17/2016] [Indexed: 12/16/2022] Open
Abstract
Background Hepatopulmonary syndrome (HPS) is a relatively common complication in patients with decompensated cirrhosis. Our aim was to evaluate the prevalence of HPS, its clinical impact, and the possible association between HPS and characteristics of patients with decompensated cirrhosis. Methods Patients with stable decompensated cirrhosis admitted to our department and assessed for HPS were included. For each patient, several clinical, laboratory and echocardiographic parameters as well as renal function were recorded. The severity of liver disease was evaluated according to the Model for End-stage Liver Disease and Child-Pugh scores, and renal function was assessed using 51chromium complexed with ethylene diamine tetracetic acid. In addition, the short synacthen test was performed in each patient to evaluate the adrenal function. Results Sixty-three patients were enrolled, 26 (41.3%) of whom diagnosed with HPS. In multivariate analysis, the presence of hepatocellular carcinoma [odds ratio (OR) 8.1, 95% confidence interval (CI) 5.3-27.9, P=0.045] and salivary cortisol at T60 (60 min after the intravenous injection of 250 μg corticotropin) (OR 0.88, 95%CI 0.71-0.98, P=0.045) were the factors independently associated with HPS. T60 salivary cortisol had relatively good discriminative ability for the presence of HPS (area under the curve=0.73). The presence of HPS was not associated with the outcome (P=0.22). Conclusion In our cohort of patients with decompensated cirrhosis, the presence of hepatocellular carcinoma and T60 salivary cortisol were the only factors independently associated with HPS.
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Affiliation(s)
- Stergios Soulaidopoulos
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Ioannis Goulis
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - George Giannakoulas
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki (George Giannakoulas, Theofilos Panagiotidis, Haralampos Karvounis), Thessaloniki, Greece
| | - Theofilos Panagiotidis
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki (George Giannakoulas, Theofilos Panagiotidis, Haralampos Karvounis), Thessaloniki, Greece
| | - Petros Doumtsis
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Areti Karasmani
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Theodora Oikonomou
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Theodora Tzoumari
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
| | - Haralampos Karvounis
- First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki (George Giannakoulas, Theofilos Panagiotidis, Haralampos Karvounis), Thessaloniki, Greece
| | - Εvangelos Cholongitas
- 4 Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki (Stergios Soulaidopoulos, Ioannis Goulis, Petros Doumtsis, Areti Karasmani, Theodora Oikonomou, Theodora Tzoumari, Evangelos Cholongitas)
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Bertino G, Privitera G, Purrello F, Demma S, Crisafulli E, Spadaro L, Koukias N, Tsochatzis EA. Emerging hepatic syndromes: pathophysiology, diagnosis and treatment. Intern Emerg Med 2016; 11:905-16. [PMID: 27273018 DOI: 10.1007/s11739-016-1478-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide, mainly due to complications of portal hypertension. In this article, we review the current understanding on the pathophysiology, the diagnostic criteria and the available therapeutic options for patients with emerging hepatic syndromes in cirrhosis, namely the hepatorenal, hepato-adrenal and hepatopulmonary syndrome. The hepatorenal syndrome is a well-recognized complication of advanced cirrhosis and is usually associated with an accelerated course to death unless liver transplantation is performed. The hepatopulmonary syndrome is often missed in the evaluation of patients with cirrhosis; however, early recognition is essential for the efficient management of individual patients. The hepato-adrenal syndrome, although not fully characterized, offers an exciting field for research and potential therapeutic interventions.
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Affiliation(s)
- Gaetano Bertino
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Graziella Privitera
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Francesco Purrello
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Shirin Demma
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Emanuele Crisafulli
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Luisa Spadaro
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Nikolaos Koukias
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
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Khositseth A, Treepongkaruna S, Khemakanok K, Teeraratkul S, Pansrimangkorn V, Thirapattaraphan C, Leelaudomlipi S. Intrapulmonary vascular dilation in children with chronic liver diseases: pre- and post-liver transplantation. Ann Hepatol 2016; 15:47-52. [PMID: 26626640 DOI: 10.5604/16652681.1184207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS Chronic liver disease (CLD) can cause hepatopulmonary syndrome (HPS), defined as triad of liver disease, hypoxemia, and intrapulmonary vascular dilation (IPVD). The aim of this study was to determine the evidence of IPVD in a cohort of pediatric patients with CLD pre- and post-liver transplantation (LT). MATERIAL AND METHODS All pediatric patients with CLD listed for LT were studied. Pulse oxygen saturation (SpO(2)), technetium-99m-labeled macroaggregated albumin ((99m)Tc- MAA) perfusión scan (positive test: uptake of the isotope ≥ 6% in the brain), and echocardiography with saline bubble test (SBT) were performed. SBT was re-evaluated at 3-6 months after LT. Grading of SBT included grade 0 (no bubble), I (1-9 bubbles), grade II (10-20 bubbles), and grade III (> 20 bubbles). RESULTS Eighteen patients, median age 22.5 months (8-108), were enrolled. Most had biliary atresia (77.8%). Pre-LT, all patients had SpO(2) of 100% and none had positive (99)mTc- MAA perfusion scan. Two patients (11%) had negative SBT (grade 0), 1 (5.5%) had grade I, 3 (16.5%) had grade II, and 12 (67%) had grade III, respectively. Post-LT SBT became negative in all survivors (n = 16), (p = 0.0001). CONCLUSIONS Most cirrhotic children in this cohort study had evidence of IPVD by positive SBT. However, none of these met the criteria for diagnosis of HPS. This evidence of IPVD subsided after LT.
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Affiliation(s)
- Anant Khositseth
- Department of Surgery. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Department of Pediatrics. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Khemika Khemakanok
- Department of Surgery. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sumate Teeraratkul
- Department of Surgery. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vichai Pansrimangkorn
- Department of Surgery. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Surasak Leelaudomlipi
- Department of Pediatrics. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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CT Scan Does Not Differentiate Patients with Hepatopulmonary Syndrome from Other Patients with Liver Disease. PLoS One 2016; 11:e0158637. [PMID: 27384058 PMCID: PMC4934684 DOI: 10.1371/journal.pone.0158637] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/20/2016] [Indexed: 01/14/2023] Open
Abstract
Background Hepatopulmonary syndrome (HPS) is defined by liver dysfunction, intrapulmonary vascular dilatations, and impaired oxygenation. The gold standard for detection of intrapulmonary vascular dilatations in HPS is contrast echocardiography. However, two small studies have suggested that patients with HPS have larger segmental pulmonary arterial diameters than both normal subjects and normoxemic subjects with cirrhosis, when measured by CT. We sought to compare CT imaging-based pulmonary vasodilatation in patients with HPS, patients with liver dysfunction without HPS, and matching controls on CT imaging. Methods We performed a retrospective cohort study at two quaternary care Canadian HPS centers. We analyzed CT thorax scans in 23 patients with HPS, 29 patients with liver dysfunction without HPS, and 52 gender- and age-matched controls. We measured the artery-bronchus ratios (ABRs) in upper and lower lung zones, calculated the “delta ABR” by subtracting the upper from the lower ABR, compared these measurements between groups, and correlated them with clinically relevant parameters (partial pressure of arterial oxygen, alveolar-arterial oxygen gradient, macroaggregated albumin shunt fraction, and diffusion capacity). We repeated measurements in patients with post-transplant CTs. Results Patients had significantly larger lower zone ABRs and delta ABRs than controls (1.20 +/- 0.19 versus 0.98 +/- 0.10, p<0.01; and 0.12 +/- 0.17 versus -0.06 +/- 0.10, p<0.01, respectively). However, there were no significant differences between liver disease patients with and without HPS, nor any significant correlations between CT measurements and clinically relevant parameters. There were no significant changes in ABRs after liver transplantation (14 patients). Conclusions Basilar segmental artery-bronchus ratios are larger in patients with liver disease than in normal controls, but this vasodilatation is no more severe in patients with HPS. CT does not distinguish patients with HPS from those with uncomplicated liver disease.
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Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients—Part II. Crit Care Med 2016; 44:1206-27. [DOI: 10.1097/ccm.0000000000001847] [Citation(s) in RCA: 239] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension. PLoS One 2016; 11:e0154011. [PMID: 27119143 PMCID: PMC4847763 DOI: 10.1371/journal.pone.0154011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 04/07/2016] [Indexed: 02/07/2023] Open
Abstract
Objective The aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni. Location The University of São Paulo Medical School, Brazil; Public Practice. Methods Hemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15). Results The cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05). Conclusions The late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.
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Cosarderelioglu C, Cosar AM, Gurakar M, Dagher NN, Gurakar A. Hepatopulmonary Syndrome and Liver Transplantation: A Recent Review of the Literature. J Clin Transl Hepatol 2016; 4:47-53. [PMID: 27047772 PMCID: PMC4807143 DOI: 10.14218/jcth.2015.00044] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 12/14/2022] Open
Abstract
A severe and common pulmonary vascular complication of liver disease is hepatopulmonary syndrome (HPS). It is a triad of liver dysfunction and/or portal hypertension, intrapulmonary vascular dilatations, and increased alveolar-arterial oxygen gradient. Prevalence varies according to various study groups from 4%-47%. While the most common presenting symptom of HPS is dyspnea, it is usually asymptomatic, and thus all liver transplant candidates should be screened for its presence. Pulse oximetry is a useful screening method, but arterial blood gas examination is the gold standard. If there is an abnormal P (A-a)O2 gradient, microbubble transthoracic echocardiography should be done for diagnosis. Outcome is unpredictable, and there is currently no effective medical therapy. The only effective therapy is considered to be liver transplantation. Complete resolution of HPS after liver transplantation is seen within a year in most HPS patients.
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Affiliation(s)
- Caglar Cosarderelioglu
- Johns Hopkins University School of Medicine, Department of Gastroenterology/Hepatology, Baltimore, MD, USA
| | - Arif M. Cosar
- Johns Hopkins University School of Medicine, Department of Gastroenterology/Hepatology, Baltimore, MD, USA
| | - Merve Gurakar
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Nabil N. Dagher
- Johns Hopkins University School of Medicine, Department of Surgery/Liver Transplant, Baltimore, MD, USA
| | - Ahmet Gurakar
- Johns Hopkins University School of Medicine, Department of Gastroenterology/Hepatology, Baltimore, MD, USA
- Correspondence to: Ahmet Gurakar, 720 Rutland Avenue, Ross Research Building, Suite #918, Baltimore, Maryland, 21205, USA, Tel: 410-614-3369, Fax: 410-367-2328, E-mail:
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Kaneko Y, Torisu S, Hagio M, Yamaguchi R, Mizutani S, Naganobu K. A case report of suspected hepatopulmonary syndrome secondary to ductal plate malformation with chronic active hepatitis in a dog. J Vet Med Sci 2015; 78:493-7. [PMID: 26616155 PMCID: PMC4829524 DOI: 10.1292/jvms.15-0425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is a respiratory complication of hepatic disease, that is
well recognized in humans and defined by the presence of 1) liver disease, 2) hypoxemia
and/or high alveolar-arterial oxygen gradient (AaDO2) and 3) intrapulmonary
vasodilatation. The present report describes a similar case of HPS in a dog. A
six-month-old Papillon was diagnosed with ductal plate malformation with chronic active
hepatitis and showed progressive increases in AaDO2 over the course of the
following six months. The presence of intrapulmonary vasodilatation was confirmed by
agitated saline contrast transthoracic echocardiography. Also, the absence of congenital
cardiac defect was confirmed by transthoracic echocardiography. From these results, we
suspected that this dog had HPS. This is the first description of suspected canine
HPS.
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Affiliation(s)
- Yasuyuki Kaneko
- Veterinary Teaching Hospital, Faculty of Agriculture, University of Miyazaki, 1-1 Gakuen Kibanadai-nishi, Miyazaki 889-2192, Japan
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Werlang ME, Palmer WC, Boyd EA, Cangemi DJ, Harnois DM, Taner CB, Stancampiano FF. Patent foramen ovale in liver transplant recipients does not negatively impact short-term outcomes. Clin Transplant 2015; 30:26-32. [PMID: 26448343 DOI: 10.1111/ctr.12643] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 11/28/2022]
Abstract
AIM Patent foramen ovale (PFO) is a common atrial septal defect that is largely asymptomatic and often undiagnosed. The impact of a PFO in patients undergoing liver transplantation (LT) is unknown. OBJECTIVE Assess the impact of PFO and physiologic intrapulmonary shunt (IPS) on the perioperative outcomes of patients who underwent LT. METHODS We performed a retrospective, intention-to-treat analysis of patients with PFO and controls without PFO who underwent LT at Mayo Clinic in Florida between 2008 and 2013. Patients with physiologic IPS were also analyzed. The cohorts were compared for baseline characteristics, length of stay in the intensive care unit (ICU), postoperative oxygen requirements, 30-d cerebrovascular accidents, and mortality. RESULTS Of the 935 patients who underwent LT, 10.4% had proven PFO by pre-LT echocardiogram. Control patients (n = 101) were statistically older than PFO and IPS (n = 56) patients, but similar in sex, BMI, Model for End-stage Liver Disease score, American Society of Anesthesiologist score, and left ventricular ejection fraction. PFO and IPS patients had similar length of stay in the ICU, mechanical ventilation times, post-LT oxygen requirements, and 30-d mortality compared to controls. Subgroup analysis showed similar outcomes for large PFO and IPS patients to controls. CONCLUSIONS The presence of PFO did not have a negative impact on perioperative LT outcomes.
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Affiliation(s)
- Monia E Werlang
- Department of Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - William C Palmer
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - David J Cangemi
- Department of Digestive and Liver Diseases, Gastroenterology, University of Texas Southwestern, Dallas, TX, USA
| | - Denise M Harnois
- Division of Transplant Hepatology, Department of Transplantation, Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Cemal B Taner
- Division of Transplant Hepatology, Department of Transplantation, Mayo Clinic College of Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
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Kaneko Y, Torisu S, Kobayashi T, Mizutani S, Tsuzuki N, Sonoda H, Ikeda M, Naganobu K. Arterial blood gas anomaly in canine hepatobiliary disease. J Vet Med Sci 2015; 77:1633-8. [PMID: 26256228 PMCID: PMC4710720 DOI: 10.1292/jvms.15-0169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Arterial blood gas analysis is an important diagnostic and monitoring tool for
respiratory abnormalities. In human medicine, lung complications often occur as a result
of liver disease. Although pulmonary complications of liver disease have not been reported
in dogs, we have frequently encountered hypoxemia in dogs with liver disorders, especially
extrahepatic biliary obstruction. In addition, respiratory disorders account for 20% of
perioperative fatalities in dogs. Therefore, in this study, we evaluated the respiratory
status in dogs with hepatobiliary disease by arterial blood gas analysis. PaO2
and PaCO2 were measured. Alveolar-arterial oxygen difference
(AaDO2), the indicator of gas exchange efficiency, was calculated. Compared to
healthy dogs (control group), hepatobiliary disease dogs had significantly lower
PaO2 and higher AaDO2. Hypoxemia (PaO2 of ≤80 mmHg) was
observed in 28/71 dogs with hepatobiliary disease. AaDO2 was higher (≥30 mmHg)
than the control group range (11.6 to 26.4 mmHg) in 32/71 hepatobiliary disease dogs. By
classifying type of hepatobiliary disease, dogs with extrahepatic biliary obstruction and
chronic hepatitis showed significantly lower PaO2 and higher AaDO2
than in a control group. Dogs with chronic hepatitis also had significantly lower
PaCO2. The present study shows that dogs with hepatobiliary disease have
respiratory abnormalities more than healthy dogs. Preanesthetic or routine arterial blood
gas analysis is likely beneficial to detect the respiratory abnormalities in dogs with
hepatobiliary disease, especially extrahepatic biliary obstruction and chronic
hepatitis.
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Affiliation(s)
- Yasuyuki Kaneko
- Veterinary Teaching Hospital, Faculty of Agriculture, University of Miyazaki, 1-1 Gakuen Kibanadai-nishi, Miyazaki-shi, Miyazaki 889-2192, Japan
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de Queiro´s ASS. Reply to ‘Accurate measurement of the normality values of macroaggregated albumin lung perfusion scan in hepatopulmonary syndrome’. Ann Nucl Med 2015; 29:756. [DOI: 10.1007/s12149-015-1004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/05/2015] [Indexed: 10/23/2022]
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Accurate measurement of the normality values of macroaggregated albumin lung perfusion scan in hepatopulmonary syndrome. Ann Nucl Med 2015; 29:754-5. [PMID: 26184840 DOI: 10.1007/s12149-015-1001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/25/2015] [Indexed: 02/05/2023]
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Abstract
Hepatopulmonary syndrome (HPS) is a pulmonary complication observed in patients with chronic liver disease and/or portal hypertension, attributable to an intrapulmonary vascular dilatation that may induce severe hypoxemia. Microvascular dilation and angiogenesis in the lung have been identified as pathologic features that drive gas exchange abnormalities in experimental HPS. Pulse oximetry is a useful screening test for HPS, which can guide subsequent use of arterial blood gases. Contrast-enhanced echocardiography, perfusion lung scanning, and pulmonary arteriography are three currently used diagnostic imaging modalities that identify the presence of intrapulmonary vascular abnormalities. The presence of HPS increases mortality and impairs quality of life, but is reversible with liver transplantation. No medical therapy is established as effective for HPS. At the present time, liver transplantation is the only available treatment for HPS.
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Affiliation(s)
- Yong Lv
- Department of Liver Disease, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China,
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Zhao H, Tsauo J, Ma HY, Li X. The role of macroaggregated albumin lung perfusion scan in hepatopulmonary syndrome: are we ready to draw conclusions? Liver Int 2015; 35:1918-9. [PMID: 25688443 DOI: 10.1111/liv.12810] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- He Zhao
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiaywei Tsauo
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huai Y Ma
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao Li
- Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Cuadrado A, Díaz A, Iruzubieta P, Salcines JR, Crespo J. Síndrome hepatopulmonar. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:398-408. [DOI: 10.1016/j.gastrohep.2015.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/01/2015] [Accepted: 02/08/2015] [Indexed: 12/17/2022]
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Raevens S, Geerts A, Van Steenkiste C, Verhelst X, Van Vlierberghe H, Colle I. Hepatopulmonary syndrome and portopulmonary hypertension: recent knowledge in pathogenesis and overview of clinical assessment. Liver Int 2015; 35:1646-60. [PMID: 25627425 DOI: 10.1111/liv.12791] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/17/2015] [Indexed: 12/14/2022]
Abstract
Hepatopulmonary syndrome and portopulmonary hypertension are cardiopulmonary complications, which are not infrequently seen in patients with liver disease and/or portal hypertension. These entities are both clinically and pathophysiologically different: the hepatopulmonary syndrome is characterized by abnormal pulmonary vasodilation and right-to-left shunting resulting in gas exchange abnormalities, whereas portopulmonary hypertension is caused by pulmonary artery vasoconstriction leading to hemodynamic failure. As both hepatopulmonary syndrome and portopulmonary hypertension are associated with significantly increased morbidity and mortality, and as these patients are commonly asymptomatic, all liver transplantation candidates should be actively screened for the presence of these two complications. The aim of is this review is to provide an overview on the hepatopulmonary syndrome and portopulmonary hypertension with primary focus on diagnosis and recent knowledge regarding pathogenesis and therapeutic targets.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Anja Geerts
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Christophe Van Steenkiste
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium.,Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Colle
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium.,Department of Gastroenterology and Hepatology, Algemeen Stedelijk Ziekenhuis ASZ, Aalst, Belgium
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Surasi DS, Manapragada P, Bhambhvani P. Lung perfusion imaging in hepatopulmonary syndrome using (99m)Tc macroaggregated albumin. J Nucl Cardiol 2015; 22:586-8. [PMID: 25164140 DOI: 10.1007/s12350-014-9990-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatopulmonary syndrome is a serious pulmonary vascular complication in patients with chronic liver disease. It constitutes a triad of chronic liver disease, increased alveolar-arterial oxygen gradient, and evidence of intrapulmonary shunt (IPS). The diagnosis of IPS can be made by bubble echocardiography, technetium-99m-labeled macroaggregated albumin ((99m)Tc-MAA) scintigraphy or pulmonary arteriography. Though echocardiography is a sensitive screening test, MAA scintigraphy can also quantify the extent of shunting.
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Affiliation(s)
- Devaki Shilpa Surasi
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA,
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72
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Younis I, Sarwar S, Butt Z, Tanveer S, Qaadir A, Jadoon NA. Clinical characteristics, predictors, and survival among patients with hepatopulmonary syndrome. Ann Hepatol 2015. [PMID: 25864216 DOI: 10.1016/s1665-2681(19)31275-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) is a complication of advanced liver disease. The impact of HPS on survival is not clearly understood. MATERIAL AND METHODS A prospective study was carried out at Department of Medicine, King Edward Medical University Lahore from June 2011 to May 2012. Patients with cirrhosis of liver were evaluated for presence of HPS with arterial blood gas analysis and saline bubble echocardiography. All patients were followed for 6 months for complications and mortality. Cox regression analysis was done to evaluate role of HPS on patient survival. RESULTS 110 patients were included in the study. Twenty-nine patients (26%) had HPS. MELD score was significantly higher (p < 0.01) in patients with HPS (18.93 ± 3.51) as compared to that in patients without HPS (13.52 ± 3.3). Twenty two (75.9%) patients of Child class C, 5 (17.2%) patients of Child class B and 2 (6.9%) patients of Child class A had HPS (P 0.03). The clinical variables associated with presence of HPS were spider nevi, digital clubbing, dyspnea, and platypnea. HPS significantly increased mortality during six month follow up period (HR: 2.47, 95% CI: 1.10- 5.55). Child-Pugh and MELD scores were also associated with increased mortality. HPS was no longer associated with mortality when adjustment was done for age, gender, Child-Pugh, and MELD scores (HR: 0.44, 95% CI: 0.14-1.41). Both the Child-Pugh and MELD scores remained significantly associated with mortality in the multivariate survival analysis. CONCLUSIONS HPS indicates advanced liver disease. HPS does not affect mortality when adjusted for severity of cirrhosis.
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Affiliation(s)
| | | | - Zeeshan Butt
- Prince George's Hospital Center, Cheverly MD, USA
| | | | | | - Nauman Arif Jadoon
- Center for Biomedical Research, Lahore, Pakistan; Nishtar Medical College Hospital, Multan-Pakistan
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Ramírez Moreno JM, Millán Núñez MV, Rodríguez Carrasco M, Ceberino D, Romaskevych-Kryvulya O, Constantino Silva AB, Muñoz-Vega P, García-Corrales C, Guiberteau-Sánchez A, Roa Montero A, Márquez-Lozano P, Narváez Rodríguez I. [Detection of an intrapulmonary shunt in patients with liver cirrhosis through contrast-enhanced transcranial Doppler. A study of prevalence, pattern characterization, and diagnostic validity]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:475-83. [PMID: 25841632 DOI: 10.1016/j.gastrohep.2015.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/14/2015] [Accepted: 02/23/2015] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Intrapulmonary vascular dilatations (IPVD) are considered a complication of cirrhosis. The technique of choice for their diagnosis is contrast-enhanced echocardiography (CEE). The aim of this study was to determine the usefulness of contrast-enhanced transcranial Doppler (CETD) in the diagnosis of IPVD. METHOD We consecutively included patients evaluated for liver transplantation. A cross-sectional study was conducted. The investigator interpreting CETD was blind to the results of the gold standard (CEE). The accuracy of the diagnostic test was evaluated through sensitivity, specificity, positive and negative predictive values, and likelihood ratio. RESULTS CETD (n=43) showed a right-to-left shunt in 23 patients (62.2%): 4 early, 2 indeterminate and 17 late. Nineteen (51,4%) cases were classified as IPVD. With CEE (n=37), 10 procedures (27%) were negative for shunt, 27 (73%) were positive, and 21 (56.8%) were compatible with IPVD. Patients with and without IPVD showed no differences in age, sex, etiology, severity, or MELD score, independently of the diagnostic test. In the diagnostic validity study (n=37) of CETD versus CEE, the AUC for diagnostic yield was 0.813% (95%CI: 0.666-0.959; P=.001), sensitivity was 76.2% (95%CI: 54.9-89.4) and specificity was 90% (95%CI: 63.9-96.5). The positive likelihood ratio was 6.095. CONCLUSIONS We found a high prevalence of IPVD in candidates for liver transplantation. When a late right-to-left shunt with recirculation is observed, CETD has a high probability of detecting IPVD, with few false-positive results. Because this technique has not previously been described in this indication, similar studies are needed for comparison.
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Affiliation(s)
| | | | | | - David Ceberino
- Servicio de Neurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
| | | | | | - Pedro Muñoz-Vega
- Servicio de Neurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
| | - Carmen García-Corrales
- Servicio de Cardiología, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
| | | | - Ana Roa Montero
- Servicio de Neurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
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Velthuis S, Buscarini E, Gossage JR, Snijder RJ, Mager JJ, Post MC. Clinical implications of pulmonary shunting on saline contrast echocardiography. J Am Soc Echocardiogr 2015; 28:255-63. [PMID: 25623000 DOI: 10.1016/j.echo.2014.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 02/07/2023]
Abstract
Pulmonary right-to-left shunting can be encountered using transthoracic contrast echocardiography (TTCE) with agitated saline. Diseases associated with pulmonary shunting on saline TTCE include hereditary hemorrhagic telangiectasia (HHT), hepatopulmonary syndrome, and some congenital heart defects after partial or complete cavopulmonary anastomosis. Furthermore, small pulmonary shunts on saline TTCE are also documented in a proportion of healthy individuals. Pulmonary shunting carries the risk for severe neurologic complications due to paradoxical embolization. In HHT, additional chest computed tomography is recommended in case of any pulmonary shunt detected on saline TTCE, to evaluate the feasibility for transcatheter embolotherapy of pulmonary arteriovenous malformations. Furthermore, antibiotic prophylaxis is advised in case of any pulmonary shunt on saline TTCE to prevent brain abscesses after procedures with risk for bacteremia. The present review provides an overview of important aspects of pulmonary shunting and its detection using saline TTCE. Furthermore, advances in understanding the clinical implications of different pulmonary shunt grades on saline TTCE are described. It appears that small pulmonary shunts on saline TTCE (grade 1) lack any clinical implication, as these shunts cannot be used as a diagnostic criterion for HHT, are not associated with an increased risk for neurologic complications, and represent pulmonary arteriovenous malformations too small for subsequent endovascular treatment. This implies that additional chest computed tomography could be safely withheld in all persons with only small pulmonary shunts on saline TTCE and sets the stage for further discussion about the need for antibiotic prophylaxis in these subjects. Besides further optimization of the current screening algorithm for the detection of pulmonary arteriovenous malformations in HHT, these observations can be of additional clinical importance in other diseases associated with pulmonary shunting and in those healthy individuals with documented small pulmonary shunts on saline TTCE.
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Affiliation(s)
- Sebastiaan Velthuis
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.
| | | | - James R Gossage
- Department of Medicine, Georgia Regents University, Augusta, Georgia
| | - Repke J Snijder
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn C Post
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
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75
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El-Habashy MM, Khamis AA, Kamel M, Essa A, Shehab-Eldin W, Shaban M. Hepatopulmonary syndrome in noncirrhotic patients with chronic viral hepatitis. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2014. [DOI: 10.4103/1687-8426.145728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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76
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Yang W, Hu B, Wu W, Batra S, Blackburn MR, Alcorn JL, Fallon MB, Zhang J. Alveolar type II epithelial cell dysfunction in rat experimental hepatopulmonary syndrome (HPS). PLoS One 2014; 9:e113451. [PMID: 25419825 PMCID: PMC4242631 DOI: 10.1371/journal.pone.0113451] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/24/2014] [Indexed: 12/18/2022] Open
Abstract
The hepatopulmonary syndrome (HPS) develops when pulmonary vasodilatation leads to abnormal gas exchange. However, in human HPS, restrictive ventilatory defects are also observed supporting that the alveolar epithelial compartment may also be affected. Alveolar type II epithelial cells (AT2) play a critical role in maintaining the alveolar compartment by producing four surfactant proteins (SPs, SP-A, SP-B, SP-C and SP-D) which also facilitate alveolar repair following injury. However, no studies have evaluated the alveolar epithelial compartment in experimental HPS. In this study, we evaluated the alveolar epithelial compartment and particularly AT2 cells in experimental HPS induced by common bile duct ligation (CBDL). We found a significant reduction in pulmonary SP production associated with increased apoptosis in AT2 cells after CBDL relative to controls. Lung morphology showed decreased mean alveolar chord length and lung volumes in CBDL animals that were not seen in control models supporting a selective reduction of alveolar airspace. Furthermore, we found that administration of TNF-α, the bile acid, chenodeoxycholic acid, and FXR nuclear receptor activation (GW4064) induced apoptosis and impaired SP-B and SP-C production in alveolar epithelial cells in vitro. These results imply that AT2 cell dysfunction occurs in experimental HPS and is associated with alterations in the alveolar epithelial compartment. Our findings support a novel contributing mechanism in experimental HPS that may be relevant to humans and a potential therapeutic target.
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Affiliation(s)
- Wenli Yang
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Bingqian Hu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Wei Wu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Sachin Batra
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Michael R. Blackburn
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Joseph L. Alcorn
- Division of Neonatology, Department of Pediatrics, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Michael B. Fallon
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Junlan Zhang
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
- * E-mail:
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Licata A, Mazzola A, Ingrassia D, Calvaruso V, Cammà C, Craxì A. Clinical implications of the hyperdynamic syndrome in cirrhosis. Eur J Intern Med 2014; 25:795-802. [PMID: 25245607 DOI: 10.1016/j.ejim.2014.09.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/02/2014] [Accepted: 09/04/2014] [Indexed: 12/24/2022]
Abstract
The hyperdynamic syndrome is a late consequence of portal hypertension in cirrhosis. The principal hemodynamic manifestations of the hyperdynamic syndrome are high cardiac output, and increased heart rate and total blood volume, accompanied by reduced total systemic vascular resistance. Pathophysiology involves a complex of humoral and neural mechanisms that can determine hemodynamic changes, and lead to hyperdynamic circulation. In this review we focus our attention on the manifestations of the hyperdynamic syndrome. Some of these are well described and directly related to portal hypertension (varices, ascites, hepatic encephalopathy, and hepatorenal syndrome), while others, such as hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy, are less known as clinical manifestations related to cirrhosis and, therefore, merit further investigation.
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Affiliation(s)
- Anna Licata
- Sezione di Gastroenterologia & Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Sezione di Gastroenterologia & Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Daniela Ingrassia
- Sezione di Gastroenterologia & Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Vincenza Calvaruso
- Sezione di Gastroenterologia & Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Calogero Cammà
- Sezione di Gastroenterologia & Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Antonio Craxì
- Sezione di Gastroenterologia & Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, DIBIMIS, Università di Palermo, Palermo, Italy
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DellaVolpe JD, Garavaglia JM, Huang DT. Management of Complications of End-Stage Liver Disease in the Intensive Care Unit. J Intensive Care Med 2014; 31:94-103. [PMID: 25223828 DOI: 10.1177/0885066614551144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 07/14/2014] [Indexed: 12/19/2022]
Abstract
The management of critically ill patients with end-stage liver disease can be challenging due to the vulnerability of this population and the wide-ranging complications of the disease. This review proposes an approach based on the major organ systems affected, to provide a framework for managing the most common complications. Although considerable practice variation exists, a focus on the evidence behind the most common practices will ensure the development of the optimal skillset to appropriately manage this disease.
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Affiliation(s)
- Jeffrey D DellaVolpe
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey M Garavaglia
- Department of Pharmacy & Therapeutics, Transplant Intensive Care Unit, UPMC Presbyterian Shadyside, Pittsburgh, PA, USA
| | - David T Huang
- Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Fuhrmann V, Drolz A, Rutter K, Horvatits T. HPS: Diagnosis, clinical features, and medical therapy. Clin Liver Dis (Hoboken) 2014; 4:46-49. [PMID: 30992920 PMCID: PMC6448732 DOI: 10.1002/cld.402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/26/2014] [Accepted: 06/20/2014] [Indexed: 02/04/2023] Open
Affiliation(s)
- Valentin Fuhrmann
- Martinistraβe 52, University Medical Center Hamburg Eppendorf, Hamburg, Germany. Phone: +49‐40‐7410‐0.
| | - Andreas Drolz
- Martinistraβe 52, University Medical Center Hamburg Eppendorf, Hamburg, Germany. Phone: +49‐40‐7410‐0.
| | - Karoline Rutter
- Martinistraβe 52, University Medical Center Hamburg Eppendorf, Hamburg, Germany. Phone: +49‐40‐7410‐0.
| | - Thomas Horvatits
- Martinistraβe 52, University Medical Center Hamburg Eppendorf, Hamburg, Germany. Phone: +49‐40‐7410‐0.
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Aldenkortt F, Aldenkortt M, Caviezel L, Waeber JL, Weber A, Schiffer E. Portopulmonary hypertension and hepatopulmonary syndrome. World J Gastroenterol 2014; 20:8072-8081. [PMID: 25009379 PMCID: PMC4081678 DOI: 10.3748/wjg.v20.i25.8072] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are two frequent complications of liver disease, with prevalence among liver transplant candidates of 6% and 10%, respectively. Both conditions result from a lack of hepatic clearance of vasoactive substances produced in the splanchnic territory. Subsequently, these substances cause mainly pulmonary vascular remodeling and some degree of vasoconstriction in POPH with resulting elevated pulmonary pressure and right ventricular dysfunction. In HPS the vasoactive mediators cause intrapulmonary shunts with hypoxemia. Medical treatment is disappointing overall. Whereas liver transplantation (LT) results in the disappearance of HPS within six to twelve months, its effect on POPH is highly unpredictable. Modern strategies in managing HPS and POPH rely on a thorough screening and grading of the disease’s severity, in order to tailor the appropriate therapy and select only the patients who will benefit from LT. The anesthesiologist plays a central role in managing these high-risk patients. Indeed, the important hemodynamic and respiratory modifications of the perioperative period must be avoided through continuation of the preoperatively initiated drugs, appropriate intraoperative monitoring and proper hemodynamic and respiratory therapies.
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81
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Intrapulmonary vascular dilatation evaluated by 99mTc-MAA scintigraphy and its association with portal hypertension in schistosomiasis. PLoS Negl Trop Dis 2014; 8:e2881. [PMID: 24967578 PMCID: PMC4072598 DOI: 10.1371/journal.pntd.0002881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 04/07/2014] [Indexed: 12/14/2022] Open
Abstract
Background Portal hypertension is responsible for various complications in patients with schistosomiasis, among them intrapulmonary vascular dilations (IPVD). In cirrhotic patients the presence of IPVD is a sign of poor prognosis, but in patients with hepatosplenic schistosomiasis (HSS) there are no studies assessing the significance of this change. The aim of this study was to evaluate the occurrence of IPVD through 99mTc-MAA scintigraphy in patients with HSS and its relationship with clinical, laboratory, endoscopic and ultrasound parameters. Methods Cross-sectional study evaluating 51 patients with HSS. Patients were diagnosed with IPVD when the brain uptake of 99mTc-MAA was higher than 6%. Subsequently, they were divided according to presence (G1) or absence (G2) of IPVD and variables were compared between groups. Results Overall, 51 patients with mean age of 56±12 years were assessed. IPVD was observed in 31 patients (60%). There was no statistically significant differences between groups when clinical, laboratory and endoscopic parameters were compared. Regarding ultrasound parameters, the splenic vein diameter was smaller in G1 (0.9±0.3 cm) compared to G2 (1.2±0.4 cm), p = 0.029. Conclusion In patients with HSS, the occurrence of IPVD by 99mTc-MAA scintigraphy was high and was associated with lower splenic vein diameter, which can be a mechanism of vascular protection against portal hypertension. However, more studies are needed to determine the clinical significance of the early diagnosis and natural evolution of IPVD in this population. Intrapulmonary vascular dilatation (IPVD) is the key event in development of hepatopulmonary syndrome, an arterial oxygenation defect in patients with portal hypertension. IPVD diagnosis can be made by EchoDopplercardiography or 99mTc-macroaggregated albumin scintigraphy (99mTc-MAA), and ethiopatogeny is still unknown. In Northeastern Brazil, hepatosplenic schistossomiasis (HSS) is the main cause of portal hypertension. In cirrhotics, the presence of IPVD influences survival and candidacy for liver transplantation, however, in HSS patients, IPVD has been poorly studied, specially using lung perfusion scan with 99mTc-MAA. Some authors believe that IPVD is common in HSS and in the existence of differences in indirect portal hypertension parameters between patients with and without IPVD. All patients were distributed into two groups according to presence or not of IPVD, and laboratorial, endoscopy and ultrasound tests were perfomed. Occurrence of IPVD was high and was associated with lower splenic vein diameter, which can be a vascular protection mechanism against portal hypertension status.
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82
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Pascasio JM, Grilo I, López-Pardo FJ, Ortega-Ruiz F, Tirado JL, Sousa JM, Rodriguez-Puras MJ, Ferrer MT, Sayago M, Gómez-Bravo MA, Grilo A. Prevalence and severity of hepatopulmonary syndrome and its influence on survival in cirrhotic patients evaluated for liver transplantation. Am J Transplant 2014; 14:1391-9. [PMID: 24730359 DOI: 10.1111/ajt.12713] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 02/07/2014] [Accepted: 02/10/2014] [Indexed: 01/25/2023]
Abstract
The prevalence of hepatopulmonary syndrome (HPS) and its influence on survival before and after liver transplantation (LT) remain controversial. Additionally, the chronology of post-LT reversibility is unclear. This study prospectively analyzed 316 patients with cirrhosis who were evaluated for LT in 2002-2007; 177 underwent LT at a single reference hospital. HPS was defined by a partial pressure of arterial oxygen (PaO2 ) <70 mmHg and/or an alveolar-arterial oxygen gradient (A-a PO2 ) ≥20 mmHg in the supine position and positive contrast echocardiography. The prevalence of HPS was 25.6% (81/316 patients), and most patients (92.6%) had mild or moderate HPS. High Child-Pugh scores and the presence of ascites were independently associated with HPS. Patients with and without HPS did not significantly differ in LT waiting list survival (mean 34.6 months vs. 41.6 months, respectively; log-rank, p = 0.13) or post-LT survival (mean 45 months vs. 47.6 months, respectively; log-rank, p = 0.62). HPS was reversed in all cases within 1 year after LT. One-fourth of the patients with cirrhosis who were evaluated for LT had HPS (mostly mild to moderate); the presence of HPS did not affect LT waiting list survival. HPS was always reversed after LT, and patient prognosis did not worsen.
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Affiliation(s)
- J M Pascasio
- Digestive Diseases Department, Hospital Virgen del Rocío, Sevilla, Spain
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83
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Abstract
The hepatopulmonary syndrome (HPS) is a pulmonary complication of cirrhosis and/or portal hypertension whereby patients develop hypoxemia as a result of alterations in pulmonary microvascular tone and architecture. HPS occurs in up to 30% of patients with cirrhosis. Although the degree of hypoxemia does not reliably correlate with the severity of liver disease, patients with HPS have a higher mortality than do patients with cirrhosis without the disorder. There has been progress into defining the mechanisms that lead to hypoxemia in HPS, but to date there are no therapeutic options for HPS aside from liver transplantation.
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Abstract
PURPOSE OF REVIEW To discuss the advances in the understanding of the pathophysiology of experimental and human hepatopulmonary syndrome (HPS) and in the management of HPS, particularly regarding liver transplantation. RECENT FINDINGS Advances have been made in defining the pathophysiology of HPS in experimental models as well as in human disease, including the role of endothelin-1, pulmonary monocytes, and angiogenesis. Additionally, the implications of the presence of HPS as it relates to prioritizing patients for liver transplantation and posttransplant outcomes will also be reviewed. SUMMARY Mechanisms of disease continue to be defined in HPS, providing potential targets for pharmacologic intervention. Outcomes after liver transplantation are also becoming clearer, including the management of HPS with severe hypoxemia.
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85
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Polverino F, Santoriello C, Andò F, Girbino G, Cappetta D, D'Agostino B, Vatrella A, Polverino M, Milic-Emili J. Recumbent deoxygenation in mild/moderate liver cirrhosis: the "clinodeoxia". The ortho-clino paradigm. Respir Med 2014; 108:1040-8. [PMID: 24785153 DOI: 10.1016/j.rmed.2014.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 04/01/2014] [Accepted: 04/05/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND While the effects of postural change on arterial oxygenation have been well documented in normal subjects, and attributed to the relationship of closing volume (CV) to the tidal volume, in liver cirrhosis such postural changes have been evaluated mainly in a rare, peculiar clinical end-stage condition which is characterized by increased dyspnea shifting from supine to upright position ("platypnea"). The latter is associated with worsening of PaO2 ("orthodeoxia"). We evaluated the effects of postural changes on arterial oxygenation in patients affected by mild/moderate liver cirrhosis. METHODS We performed pulmonary function tests and arterial blood gas evaluation in sitting and supine positions in 22 patients with mild/moderate liver cirrhosis, biopsy-proved, and 22 matched non-smokers control subjects. RESULTS Recumbency elicited a decrease of PaO2 (Δ(sup-sit)PaO2) in 19 out of 22 controls and in all but one cirrhotics. The magnitude of this postural change was significantly (p = 0.04) greater in cirrhotics (9.6 ± 5.3%) compared to controls (6.7 ± 3.7%). In the subset of cirrhotics younger than 60 yrs and with PaO2 greater than 80 mmHg in sitting position, the Δ(sup-sit)PaO2 in recumbency further increased to 12 ± 5.8%, significantly (p = 0.014) greater than in same subgroup of controls (7.1 ± 3.8%). CONCLUSIONS In mild/moderate liver cirrhosis the postural variations in PaO2 follow the normal trends, but are of greater magnitude probably as a consequence of hypoventilated units of lung for postural and disease-linked tidal airway closure, resulting in more pronounced recumbent hypoxemia ("clinodeoxia").
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Affiliation(s)
- Francesca Polverino
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; The Lovelace Respiratory Research Institute, Albuquerque, NM, USA; Pulmonary Department, University of Parma, Parma, Italy.
| | - Carlo Santoriello
- Department of Pulmonary Medicine, Cava de' Tirreni Hospital, Cava de' Tirreni, Italy
| | - Filippo Andò
- Lung Diseases Institute, University of Messina Medical School, Messina, Italy
| | - Giuseppe Girbino
- Lung Diseases Institute, University of Messina Medical School, Messina, Italy
| | - Donato Cappetta
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Bruno D'Agostino
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | | | - Mario Polverino
- Department of Pulmonary Medicine, Cava de' Tirreni Hospital, Cava de' Tirreni, Italy; Lung Diseases Institute, University of Messina Medical School, Messina, Italy
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86
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Ghayumi SMA, Khalafi-Nezhad A, Jowkar Z. Pulse oximeter oxygen saturation in prediction of arterial oxygen saturation in liver transplant candidates. HEPATITIS MONTHLY 2014; 14:e15449. [PMID: 24748894 PMCID: PMC3989597 DOI: 10.5812/hepatmon.15449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/06/2013] [Accepted: 02/22/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver transplant is the only definitive treatment for many patients with end stage liver disease. Presence and severity of preoperative pulmonary disease directly affect the rate of postoperative complications of the liver transplantation. Arterial blood gas (ABG) measurement, performed in many transplant centers, is considered as a traditional method to diagnose hypoxemia. Because ABG measurement is invasive and painful, pulse oximetry, a bedside, noninvasive and inexpensive technique, has been recommended as an alternative source for the ABG measurement. OBJECTIVES The aim of this study was to evaluate the efficacy of pulse oximetry as a screening tool in hypoxemia detection in liver transplant candidates and to compare the results with ABGs. PATIENTS AND METHODS Three hundred and ninety transplant candidates (237 males and 153 females) participated in this study. Arterial blood gas oxyhemoglobin saturation (SaO2) was recorded and compared with pulse oximetry oxyhemoglobin saturation (SpO2) results for each participants. The area under the curve (AUC) of receiver operating characteristic (ROC) curves was calculated by means of nonparametric methods to evaluate the efficacy of pulse oximetry to detect hypoxemia. RESULTS Roc-derived SpO2 threshold of ≤ 94% can predict hypoxemia (PaO2 < 60 mmHg) with a sensitivity of 100% and a specificity of 95%. Furthermore, there are associations between the ROC-derived SpO2 threshold of ≤ 97% and detection of hypoxemia (PaO2 < 70 mmHg) with a sensitivity of 100% and a specificity of 46%. The accuracy of pulse oximetry was not affected by the severity of liver disease in detection of hypoxemia. CONCLUSIONS Provided that SpO2 is equal to or greater than 94%, attained from pulse oximetry can be used as a reliable and accurate substitute for the ABG measurements to evaluate hypoxemia in patients with end stage liver disease.
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Affiliation(s)
| | - Abolfazl Khalafi-Nezhad
- Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Author: Abolfazl Khalafi-Nezhad, Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-7116474316, Fax: +98-7116474316, E-mail:
| | - Zahra Jowkar
- Department of Operative Dentistry, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, IR Iran
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87
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Machicao VI, Balakrishnan M, Fallon MB. Pulmonary complications in chronic liver disease. Hepatology 2014; 59:1627-37. [PMID: 24089295 DOI: 10.1002/hep.26745] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 09/12/2013] [Indexed: 12/13/2022]
Abstract
The association of chronic liver disease with respiratory symptoms and hypoxia is well recognized. Over the last century, three pulmonary complications specific to chronic liver disease have been characterized: hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH). The development of portal hypertension is fundamental in the pathogenesis of each of these disorders. HPS is the most common condition, found in 5%-30% of cirrhosis patients, manifested by abnormal oxygenation due to the development of intrapulmonary vascular dilatations. The presence of HPS increases mortality and impairs quality of life, but is reversible with liver transplantation (LT). POPH is characterized by development of pulmonary arterial hypertension in the setting of portal hypertension, and is present in 5%-10% of cirrhosis patients evaluated for LT. Screening for POPH in cirrhosis patients eligible for LT is critical since severe POPH is a relative contraindication for LT. Patients with moderate POPH, who respond adequately to medical therapy, may benefit from LT, although sufficient controlled data are lacking. HH is a transudative pleural effusion seen in 5%-10% of cirrhosis patients, in the absence of cardiopulmonary disease. Diagnosis of HH should prompt consideration for LT, which is the ultimate treatment for HH. Conservative management includes salt restriction and diuretics, with thoracentesis and transjugular intrahepatic portosystemic shunt (TIPS) as second-line therapeutic options.
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Affiliation(s)
- Victor I Machicao
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX
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88
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Tumgor G. Cirrhosis and hepatopulmonary syndrome. World J Gastroenterol 2014; 20:2586-2594. [PMID: 24627594 PMCID: PMC3949267 DOI: 10.3748/wjg.v20.i10.2586] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 01/05/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterized as a triad: liver disease, intrapulmonary vascular dilatation and arterial hypoxemia. HPS is reported to be present in 4% to 32% of adult patients with end-stage liver disease and in 9%-20% of children. The pathogenesis of HPS has not been clearly identified. Portal hypertension causes impairment in the perfusion of the bowel and increases the enteral translocation of Gram (-) bacteria and endotoxins. This stimulates the release of vasoactive mediators, such as tumor necrosis factor-alpha, heme oxygenase-derived carbon monoxide and nitric oxide. Genetic alterations have not been associated with this syndrome yet; however, cytokines and chemokines have been suggested to play a role. Recently, it was reported that cumulated monocytes lead to the activation of vascular endothelial growth factor-dependent signaling pathways and pulmonary angiogenesis, which plays an important role in HPS pathogenesis. At present, the most effective and only radical treatment is a liver transplant (LT). Cirrhotic patients who are on the waiting list for an LT have a shorter survival period if they develop HPS. Therefore, it is suggested that all cirrhotic cases should be followed closely for HPS and they should have priority in the waiting list.
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89
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Horvatits T, Fuhrmann V. Therapeutic options in pulmonary hepatic vascular diseases. Expert Rev Clin Pharmacol 2013; 7:31-42. [DOI: 10.1586/17512433.2014.857598] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gandhi SJ, Babu S, Subramanyam P, Shanmuga Sundaram P. Tc-99m macro aggregated albumin scintigraphy - indications other than pulmonary embolism: A pictorial essay. Indian J Nucl Med 2013; 28:152-62. [PMID: 24250023 PMCID: PMC3822414 DOI: 10.4103/0972-3919.119546] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Tc-99m macro aggregated albumin (MAA) is synonymous for lung perfusion scintigraphy and is part of the study in the evaluation of pulmonary thromboembolism. We wanted to highlight the utilities of Tc-99m MAA other than pulmonary embolism as a pictorial assay. MATERIALS AND METHODS Patients referred for Tc-99m MAA scintigraphy under various indications were included in this pictorial essay. Commercially available TechneScan LyoMAA cold kit from Mallinckrodt Medical B.V., Holland was used. Acquisition protocols for different indications are described in this article. Different clinical indications (e.g., pulmonary artery stenosis, hepatopulmonary syndrome, FEV1 calculation in lung surgery planning, selective internal radiation therapy planning, venography for deep venous thrombosis, left to right cardiac shunts, etc.) where Tc-99m MAA scintigraphy was asked for; how it helped in different clinical scenarios and how it can be used clinically is explained with unique and interesting case examples and images. We also reviewed the literature to look for certain remote indications of MAA imaging for the sake of completion like - (shunt scintigraphy, peritoneopleural communication, etc.). CONCLUSION Tc-99m MAA is a very useful radiopharmaceutical, which can be used for many other indications apart from the commonly used indication of lung perfusion scan in pulmonary embolism. It can provide useful clinical information in other indications, which we try to highlight in this article.
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Affiliation(s)
- Sunny J Gandhi
- Department of Nuclear Medicine and PETCT, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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91
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Khabbaza JE, Krasuski RA, Tonelli AR. Intrapulmonary shunt confirmed by intracardiac echocardiography in the diagnosis of hepatopulmonary syndrome. Hepatology 2013; 58:1514-5. [PMID: 23696309 PMCID: PMC4096290 DOI: 10.1002/hep.26482] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 04/11/2013] [Indexed: 12/07/2022]
Affiliation(s)
- Joseph E. Khabbaza
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Richard A. Krasuski
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Adriano R. Tonelli
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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92
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Polavarapu N, Tripathi D. Liver in cardiopulmonary disease. Best Pract Res Clin Gastroenterol 2013; 27:497-512. [PMID: 24090938 DOI: 10.1016/j.bpg.2013.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/12/2013] [Indexed: 01/31/2023]
Abstract
Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PoPH) are two fascinating and incompletely understood pulmonary vascular conditions seen in the setting of cirrhotic patients. Of the two HPS is more common and is primarily caused by pulmonary vasodilatation resulting in hypoxaemia and hyperdynamic circulation. PoPH is less common and conversely, pulmonary vasoconstriction and vascular remodelling occurs resulting in increased pulmonary vascular resistance. However, both conditions can co-exist and it is usually PoPH which develops in a patient with pre-existing HPS. Although these two pulmonary conditions are not common complications of chronic liver diseases, the treatment options are mainly limited to liver transplantation. Cirrhotic cardiomyopathy is closely related to haemodynamic changes in portal hypertension. The key features are normal cardiac pressures at rest, with reduced ability to compensate for physiological or iatrogenic stresses such as drug therapy or TIPSS. There is no effective therapy and outcomes after liver transplantation are variable.
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Affiliation(s)
- Naveen Polavarapu
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK
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93
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Restrepo R, Singer EF, Baram M, Restrepo R, Singer EF, Baram M. Hepatopulmonary syndrome and portopulmonary hypertension. Hosp Pract (1995) 2013; 41:62-71. [PMID: 23680738 DOI: 10.3810/hp.2013.04.1049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hepatopulmonary syndrome and portopulmonary hypertension are 2 of many diseases that affect the lungs in patients with liver disease. The 2 vascular conditions are often confused. We review both hepatopulmonary syndrome and portopulmonary hypertension to better understand their pathophysiologies, clinical presentations, tools to aid in differentiating and diagnosing the disease states, treatment options, and influences on patient prognosis. We also consider patient viability for liver transplantation.
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Affiliation(s)
- Ricardo Restrepo
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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94
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Bertot LC, Gomez EV, Almeida LA, Soler EA, Perez LB. Model for End-Stage Liver Disease and liver cirrhosis-related complications. Hepatol Int 2013. [PMID: 26201769 DOI: 10.1007/s12072-012-9403-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The Model for End-Stage Liver Disease (MELD) score has gained wide acceptance for predicting survival in patients undergoing liver transplantation. The strength of this score remains in the mathematical formula derived from a multivariate Cox regression analysis; it is a continuous scale and lacks a ceiling or a floor effect with a wide range of discrimination. It is based on objective, reproducible, and readily available laboratory data and the wide range of samples which have been validated. Liver cirrhosis complications such as ascites, encephalopathy, spontaneous bacterial peritonitis and variceal bleeding were not considered in the MELD score underestimating their direct association with the severity of liver disease. In this regard, several recent studies have shown that clinical manifestations secondary to portal hypertension are good prognostic markers in cirrhotic patients and may add additional useful prognostic information to the current MELD. We review the feasibility of MELD score as a prognostic predictor in patients with liver cirrhosis-related complications.
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Affiliation(s)
| | - Eduardo Vilar Gomez
- Department of Hepatology, National Institute of Gastroenterology, Havana, Cuba
| | | | - Enrique Arus Soler
- Department of Hepatology, National Institute of Gastroenterology, Havana, Cuba
| | - Luis Blanco Perez
- Department of Hepatology, National Institute of Gastroenterology, Havana, Cuba
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95
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Porres-Aguilar M, Gallegos-Orozco JF, Garcia H, Aguirre J, Macias-Rodriguez RU, Torre-Delgadillo A. Pulmonary vascular complications in portal hypertension and liver disease: a concise review. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:35-44. [PMID: 23369639 DOI: 10.1016/j.rgmx.2012.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 10/19/2012] [Indexed: 11/30/2022]
Abstract
Chronic liver disease and/or portal hypertension may be associated with one of the two pulmonary vascular complications: portopulmonary hypertension and hepatopulmonary syndrome. These pulmonary vascular disorders are notoriously underdiagnosed; however, they have a substantial negative impact on survival and require special attention in order to understand their diagnostic approach and to select the best therapeutic options. Portopulmonary hypertension results from excessive vasoconstriction, vascular remodeling, and proliferative and thrombotic events within the pulmonary circulation that lead to progressive right ventricular failure and ultimately to death. On the other hand, abnormal intrapulmonary vascular dilations, profound hypoxemia, and a wide alveolar-arterial gradient are the hallmarks of the hepatopulmonary syndrome, resulting in difficult-to-treat hypoxemia. The aim of this review is to summarize the latest pathophysiologic concepts, diagnostic approach, therapy, and prognosis of portopulmonary hypertension and hepatopulmonary syndrome, as well as to discuss the role of liver transplantation as a definitive therapy in selected patients with these conditions.
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Affiliation(s)
- M Porres-Aguilar
- Department of Internal Medicine, Division of Hospital Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA.
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96
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Grace JA, Angus PW. Hepatopulmonary syndrome: update on recent advances in pathophysiology, investigation, and treatment. J Gastroenterol Hepatol 2013. [PMID: 23190201 DOI: 10.1111/jgh.12061] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatopulmonary syndrome (HPS) is an important cause of dyspnea and hypoxia in the setting of liver disease, occurring in 10-30% of patients with cirrhosis. It is due to vasodilation and angiogenesis in the pulmonary vascular bed, which leads to ventilation-perfusion mismatching, diffusion limitation to oxygen exchange, and arteriovenous shunting. There is evidence, primarily from animal studies, that vasodilation is mediated by a number of endogenous vasoactive molecules, including endothelin-1 and nitric oxide (NO). In experimental HPS, liver injury stimulates release of endothelin-1 and results in increased expression of ET(B) receptors on pulmonary endothelial cells, leading to upregulation of endothelial NO synthase (eNOS) and subsequent increased production of NO, which causes vasodilation. In addition, increased phagocytosis of bacterial endotoxin in the lung not only promotes stimulation of inducible NO synthase, which increases NO production, but also contributes to intrapulmonary accumulation of monocytes, which may stimulate angiogenesis via vascular endothelial growth factor pathway. Despite these insights into the pathogenesis of experimental HPS, there is no established medical therapy, and liver transplantation remains the main treatment for symptomatic HPS, although selected patients may benefit from other surgical or radiological interventions. In this review, we focus on recent advances in our understanding of the pathophysiology of HPS, and discuss current approaches to the investigation and treatment of this condition.
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Affiliation(s)
- Josephine A Grace
- Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia.
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97
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Fritz JS, Fallon MB, Kawut SM. Pulmonary vascular complications of liver disease. Am J Respir Crit Care Med 2012; 187:133-43. [PMID: 23155142 DOI: 10.1164/rccm.201209-1583ci] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hepatopulmonary syndrome and portopulmonary hypertension are two pulmonary vascular complications of liver disease. The pathophysiology underlying each disorder is distinct, but patients with either condition may be limited by dyspnea. A careful evaluation of concomitant symptoms, the physical examination, pulmonary function testing and arterial blood gas analysis, and echocardiographic, imaging, and hemodynamic studies is crucial to establishing (and distinguishing) these diagnoses. Our understanding of the pathobiology, natural history, and treatment of these disorders has advanced considerably over the past decade; however, the presence of either still increases the risk of morbidity and mortality in patients with underlying liver disease. There is no effective medical treatment for hepatopulmonary syndrome. Although liver transplantation can resolve hepatopulmonary syndrome, there appears to be worse survival even with transplantation. Liver transplantation poses a very high risk of death in those with significant portopulmonary hypertension, where targeted medical therapies may improve functional status and allow successful transplantation in a small number of select patients.
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Affiliation(s)
- Jason S Fritz
- Department of Medicine, M.S., Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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98
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Agarwal PD, Hughes PJ, Runo JR, Ibrisim D, Lucey MR, Said A. The clinical significance of intrapulmonary vascular dilations in liver transplant candidates. Clin Transplant 2012; 27:148-53. [DOI: 10.1111/ctr.12033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2012] [Indexed: 01/26/2023]
Affiliation(s)
- P. D. Agarwal
- Division of Gastroenterology and Hepatology, Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
| | - P. J. Hughes
- Division of Cardiovascular Medicine, Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
| | - J. R. Runo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
| | - D. Ibrisim
- Division of Gastroenterology and Hepatology, Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
| | - M. R. Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
| | - A. Said
- Division of Gastroenterology and Hepatology, Department of Medicine; University of Wisconsin School of Medicine and Public Health; Madison; WI; USA
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Abstract
Hepatopulmonary syndrome (HPS) is a serious vascular complication of liver disease that occurs in 5-32% of patients with cirrhosis. The presence of HPS markedly increases mortality. No effective medical therapies are currently available and liver transplantation is the only established treatment option for HPS. The definition and diagnosis of HPS are established by the presence of a triad of liver disease with intrapulmonary vascular dilation that causes abnormal arterial gas exchange. Experimental biliary cirrhosis induced by common bile duct ligation in the rat reproduces the pulmonary vascular and gas exchange abnormalities of human HPS and serves as a pertinent animal model. Pulmonary microvascular dilation and angiogenesis are two central pathogenic features that drive abnormal pulmonary gas exchange in experimental HPS, and thus might underlie HPS in humans. Defining the mechanisms involved in the microvascular alterations of HPS has the potential to lead to effective medical therapies. This Review focuses on the current understanding of the pathogenesis, clinical features and management of HPS.
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Affiliation(s)
- Junlan Zhang
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030-1501, USA
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100
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Shneider BL, Bosch J, de Franchis R, Emre SH, Groszmann RJ, Ling SC, Lorenz JM, Squires RH, Superina RA, Thompson AE, Mazariegos GV. Portal hypertension in children: expert pediatric opinion on the report of the Baveno v Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension. Pediatr Transplant 2012; 16:426-37. [PMID: 22409296 DOI: 10.1111/j.1399-3046.2012.01652.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Complications of portal hypertension in children lead to significant morbidity and are a leading indication for consideration of liver transplantation. Approaches to the management of sequelae of portal hypertension are well described for adults and evidence-based approaches have been summarized in numerous meta-analyses and conferences. In contrast, there is a paucity of data to guide the management of complications of portal hypertension in children. An international panel of experts was convened on April 8, 2011 at The Children's Hospital of Pittsburgh of UPMC to review and adapt the recent report of the Baveno V Consensus Workshop on the Methodology of Diagnosis and Therapy in Portal Hypertension to the care of children. The opinions of that expert panel are reported.
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