Dyspnoea, clubbing, cirrhosis, and bubbles in both sides of the heart suggests hepatopulmonary syndrome

• Published in: The Lancet (British edition) Vol. 394; no. 10197; p. 510
• Main Authors: Low, Elizabeth S L, Patwala, Kurvi, Apostolov, Ross
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 10-08-2019; Elsevier Limited
• Subjects: Alveoli; Bubbles; Cirrhosis; Diagnosis; Dyspnea; Dyspnea - drug therapy; Dyspnea - etiology; Echocardiography; Heart; Heart - diagnostic imaging; Hepatopulmonary Syndrome - complications; Hepatopulmonary Syndrome - diagnosis; Hepatopulmonary Syndrome - drug therapy; Humans; Liver cirrhosis; Liver Cirrhosis - etiology; Male; Middle Aged; Osteoarthropathy, Primary Hypertrophic - etiology; Oxygen; Oxygen - administration & dosage; Oxygen - therapeutic use; Oxygen therapy; Partial pressure; Patients; Respiration; Technetium; Technetium isotopes
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(19)31720-9

An arterial blood gas while supine and breathing room air showed a partial pressure of oxygen (PaO2) of 57 mm Hg with a widened alveolar–arterial oxygen gradient (Grad[A–a] O2) of 66 mm Hg (normal gradient for a 40-year-old man is less than 14 mm Hg). To confirm the diagnosis and to investigate the patient's pathophysiology further, we did a contrast-enhanced transthoracic echocardiography, which, with saline bubbles appearing in the left side of the heart, indicated intrapulmonary right-to-left shunting (figure). A technetium-99m-labelled macroaggregated albumin scan—where radioactively labelled particles are usually prevented from passing through the pulmonary veins—may help in the diagnosis of hepatopulmonary syndrome.