[Dyspnea in a 45-year-old man with liver cirrhosis]

During evaluation for a liver transplantation in a 45-year-old man with alcoholic liver he complained of exertional dyspnea. He had grade 3 chronic obstructive pulmonary disease (COPD) after nicotine abuse of 50 pack-years. One and a half years earlier the patient had been treated for tuberculosis.

The diagnostic procedures showed a respiratory insufficiency with a PO(2) of 52 mm Hg. Notable was a missing improvement of oxygenation after the supply of 100 % oxygen. Lung perfusion scintigraphy showed a shunt of about 14 %, a contrast-medium echocardiography demonstrating a right-to-left shunt. These findings indicated that the patient had a hepatopulmonary syndrome.

The only causal therapy of a hepatopulmonary syndrome was a liver transplantation. However, the tuberculosis diagnosed one and a half years earlier had not been treated adequately, so that an antituberculotic therapy was essential before starting an immunosuppression. Therefore the only option of treatment was to continue the long-term oxygen therapy. As a matter of differential diagnosis and because of the intrapulmonary shunt, a pulmonary venous disconnection for a shunt caused by tuberculous cavities or by the COPD had to be taken into account.

Treating patients with advanced liver cirrhosis and dyspnea a hepatopulmonary syndrome must be taken into consideration. Typically there will be found a right-left-shunt. In addition, coexistent comorbidities as a reason for dyspnea have to be excluded.