SHM Converge Scientific Abstract ePoster Gallery-Hepatopulmonary Syndrome: The Case of the Misleading Shunt

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This case report describes a 60-year-old man with cirrhosis from metabolic and alcohol-associated liver disease who was found incidentally to have severe hypoxemia after a fall. Although he had no dyspnea, his oxygen saturation was 70% on room air and worsened when supine. Exam showed clubbing and cyanosis, and his arterial blood gas demonstrated hypoxemia with an elevated A–a gradient.<br /><br />Initial transthoracic echocardiography with agitated saline suggested an intracardiac shunt because bubbles appeared in the left atrium early, raising concern for an atrial septal defect or patent foramen ovale. However, further evaluation with right heart catheterization and intracardiac echo found no intracardiac shunt. A 99mTc-MAA perfusion lung scan instead showed extrapulmonary activity, confirming a right-to-left shunt from the lungs. The final diagnosis was hepatopulmonary syndrome (HPS), a complication of chronic liver disease caused by intrapulmonary vascular dilatations.<br /><br />The discussion emphasizes that HPS is a potentially reversible but high-mortality cause of hypoxemia, and liver transplantation is the definitive treatment. Importantly, the case highlights a diagnostic pitfall: in severe HPS, saline contrast echocardiography can show early bubble transit that mimics an intracardiac shunt. Therefore, clinicians should not stop the workup at a presumed ASD/PFO if the clinical picture still suggests HPS.<br /><br />The authors conclude that hospitalists play a key role in pursuing definitive testing when initial studies are misleading, to avoid missing serious but treatable disease.

Asset Subtitle

Jessica M. Guynes

Meta Tag

Author List Akriti Jalla, Erika Abel, Jessica M. Guynes, Miranda Sullivan

Category Clinical Vignettes

Concept Hepatopulmonary Syndrome

Concept Hypoxemia

Concept Intrapulmonary Vascular Dilatation

Concept Liver Transplantation

Concept Chronic Liver Disease

Distinguished Non-Finalist

Presenter Organization University of South Florida Morsani College of Medicine

Presenting Author Jessica M. Guynes

Track Adult

Keywords

hepatopulmonary syndrome

cirrhosis

hypoxemia

right-to-left shunt

intrapulmonary vascular dilatation

saline contrast echocardiography

intracardiac shunt

99mTc-MAA perfusion scan

liver transplantation

chronic liver disease

Hepatopulmonary Syndrome

Hypoxemia

Intrapulmonary Vascular Dilatation

Liver Transplantation

Chronic Liver Disease