Weekly Chest CasesArchive of Old Cases

Case No : 1158 Date 2020-01-13

  • Courtesy of Ji-yeon Han, Da Som Kim, Seok Jin Choi / Inje University Busan Paik Hospital
  • Age/Sex 72 / F
  • Chief ComplaintDyspnea, Hypoxemia
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Hepatopulmonary syndrome
Radiologic Findings
Fig 1. Chest PA shows basilar reticulonodular opacities, suggesting dilated peripheral vascular markings in both lung fields.
Fig 2-4. CT scans reveals prominent dilatation of pulmonary arteries and veins in subpleural area of both lungs.
Fig 5. CT scan at the level of upper abdomen shows lobulated bulging contour of liver with mild splenomegaly, suggesting liver cirrhosis
Brief Review
The diagnosis of hepatopulmonary syndrome is established with the following three criteria: chronic liver disease, increased alveolar-arterial gradient on room air, and evidence of intrapulmonary vascular dilatation. Hypoxemia is seen in one-third of decompensated cirrhotic patients. The most important mechanism is pulmonary vascular dilatation and consequent ventilation-perfusion mismatch. It is more accurate to describe the intrapulmonary process associated with these vascular dilatations as a diffusion-perfusion abnormality rather than as an intrapulmonary shunt. Hypoxia is believed to result from an inability of oxygen to diffuse to the center of massively dilated peripheral vessels.
Chest radiographs demonstrate basilar nodular or reticulonodular areas of increased opacity in 5%–13.8% of patients with chronic liver disease and 46%–100% of patients with hepatopulmonary syndrome. Lung volumes are preserved. Intrapulmonary arteriovenous shunting can be established with contrast (microbubble) echocardiography, technetium-99m macroaggregated albumin imaging, right-sided heart catheterization, or pulmonary arteriography. Transthoracic contrast echocardiography is performed by injecting contrast material (usually agitated saline) intravenously during echocardiography. Contrast (microbubble) generally appears in the left heart three to eight heart beats after its appearance in the right atrium when intrapulmonary shunt exists.
Computed tomography (CT) may demonstrate dilated vessels with an increased number of terminal branches extending to the pleura and can be useful in distinguishing hepatopulmonary syndrome from other causes of hypoxemia such as pulmonary fibrosis.
Please refer to
Case 113, Case 195, Case 627,
KSTR Symposium 1999  Case 5 ,
KSTR imaging conference 2017 Spring  Case 12,
References

1. Cris A. Meyer, Charles S. White, Kenneth E.Sherman. Diseases of the Hepatopulmonary Axis RadioGraphics 2009; 29:825–837
2. Tonelli AR, Naal T, Dakkak W, Park MM, Dweik RA, Stoller JK. Assessing the kinetics of microbubble appearance in cirrhotic patients using transthoracic saline contrast-enhanced echocardiography. Echocardiography. 2017;34(10):1439
Keywords
lung, vascular, hepatopulmonary Syndrome, liver cirrhosis,

No. of Applicants : 61

▶ Correct Answer : 39/61,  63.9%
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - , Korea (South) JIHYUN KIM
  • - Jiangsu province hospital , China WANGJIAN ZHA
  • - , Korea (South) JIN YOUNG LEE
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Hallym University Dongtan Medical Center , Korea (South) MINSU KIM
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Fujieda Municipal General Hospital , Japan HAYATO NOZAWA
  • - Gifu University Hospital , Japan TOMOHIRO ANDO
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - Seoul National University Hospital , Korea (South) SE WOO KIM
  • - College of Medicine, CHA University , Korea (South) PARK JONG WON
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Asan Medical Center , Korea (South) JIHOON KIM
  • - CH de la Cote Basque , France PAUL ARDILOUZE
  • - , Korea (South) HYEYOUNG CHOI
  • - Gifu University Hospital , Japan Yo Kaneko
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Immam abdullrahman bin faisal university , Saudi Arabia HIND SAIF ALSAIF
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - , Japan YUMI MAEHARA
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - Other , Korea (South) SEONGSU KANG
  • - Private sector , Greece VASILIOS TZILAS
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - , Japan KAZUMA TERAUCHI
  • - TWMU Medical Center East , Japan MASAFUMI KAIUME
  • - , Japan NAOMI YUASA
  • - Nishida Hospital , Japan SHOJI OKUDA
▶ Correct Answer as Differential Diagnosis : 2/61,  3.3%
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - Kyeongpook National University Hospital , Korea (South) MIRAN KIM
▶ Semi-Correct Answer : 1/61,  1.6%
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
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