Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Liver
Question 1#

A 53-year-old male with past medical history significant for alcoholic cirrhosis complicated by esophageal varices presents to the intensive care unit (ICU) with hypoxia. He has noticed dyspnea on exertion that has been worsening over the last several months and complains of platypnea (shortness of breath relieved by lying down). Breath sounds are clear. Chest radiography is normal and contrast chest CT is negative for pulmonary embolus.

Which of the following is the MOST definitive treatment option for his disease?

A. Broad spectrum antibiotics
B. Therapeutic paracentesis
C. Nebulized bronchodilators
D. Listing for liver transplantation
E. Bronchoscopy

Correct Answer is D

Comment:

Correct Answer: D

The history of dyspnea on exertion over a period of months in a patient with cirrhosis with portal hypertension (as evidenced by history of esophageal varices) makes hepatopulmonary syndrome a possible diagnosis. Platypnea and orthodeoxia affect up to 66% and 88% of patients with hepatopulmonary syndrome, respectively. Hepatopulmonary syndrome is progressive, and the only definitive treatment of hepatopulmonary syndrome is liver transplantation. 

Normal chest radiography and absence of symptoms such as fever, cough, or sputum production make infection less likely as the etiology of hypoxia in this case and thus antibiotics are not indicated. Although this patient may have ascites, increased abdominal pressure from ascites causing dyspnea should improve with upright positioning and worsen with supine positioning. This makes tense ascites a less likely etiology of hypoxia in this case. A normal chest radiograph and CT make a process of bronchial obstruction that could be cleared with bronchoscopy less likely.

References:

  1. Rodriques-Roisin R, Krowka MJ. Hepatopulmonary syndrome – a liverinduced lung vascular disorder. N Engl J Med. 2008;358(22):2378.
  2. 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;14(3):354-360.
  3. Gomez FP, Martínez-Pallí G, Barberà JA, et al. Gas exchange mechanism of orthodeoxia in hepatopulmonary syndrome. Hepatology. 2004;40(3):660-666.
  4. Gupta S, Castel H, Rao RV, et al. Improved survival after liver transplantation in patients with hepatopulmonary syndrome. Am J Transplant. 2010;10(2):354.