Hepatopulmonary Syndrome

This week Dr. Kartika presented an interesting case of a patient with Etoh cirrhosis who developed progressive dyspnea on exertion secondary to hepatopulmonary syndrome (HPS).

Triad of:

1. Liver disease

2. Pulmonary vascular dilation

3. Hypoxemia with increased A-a gradient

Liver dysfunction → Release or failure to clear circulating vasodilators such as Nitrous Oxide (NO) → inability to constrict pulmonary capillaries leading to relative high perfusion per ventilating unit (i.e. V-Q mismatch).

Mechanism of hypoxemia in HPS

Hepatopulmonary System Image.JPG

Diagnostic Criteria:

HPS diagnostic criteria.JPG

TTE Findings in HPS:

HPS TTE findings.JPG

Take Home Points:

1) Consider HPS in patients with cirrhosis and elevated A-a gradient

2) Diagnosis can be aided by TTE showing R—>L shunt with bubble study after 3 beats

3) TIPS controversial for treatment of HPS and in some circumstances can exacerbate intrapulmonary shunt.

N Engl J Med 2008; 358:2378-2387

Is Diamond & Forrester Outdated?? and Opioid Withdrawal Management Guidelines

Dr. Gordon presented a case of a man who presented with chest pain who's hospital stay was complicated by opioid withdrawal. 

 

We discussed our approach to evaluate a patient's pre-test probability of obstructive coronary artery disease. Current guidelines from the American College of Cardiology and the American Heart Association recommend the use of the familiar Diamond-Forrester (DF) classification system. It uses age, sex and type of angina (non-anginal, atypical and typical) to place patients into risk groups for angina. However, as Dr. Harmon pointed out, this scoring was developed with data from the 1970's and much has changed in how we evaluate patients and manage chest pain. More recent studies that attempted to validate the DF score found that it resulted in a significant overestimation of the prevalence of obstructive CAD [1]. The European Society of Cardiology has created a modified version of the DF system that uses the same clinical variables (age, sex, angina), but was developed using contemporary data.[2]

 https://qxmd.com/calculate/calculator_287/pre-test-probability-of-cad-cad-consortium

 

We also reviewed some of the guidelines for treatment of opioid withdrawal. Guidelines can be found here:

Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Geneva: World Health Organization; 2009. 4, Withdrawal Management. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310652/

 References: 

  1. Genders TS, Steyerberg EW, Alkadhi H, et al. A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. Eur Heart J. 2011;32(11):1316-30.

  2. Bittencourt MS, Hulten E, Polonsky TS, et al. European Society of Cardiology-Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score: The Partners Registry. Circulation. 2016;134(3):201-11.

  3. Ebell MH. More Accurate Prediction of the Pretest Probability of Cardiovascular Disease with European Risk Score. Am Fam Physician. 2017;95(10):Online.

  4. Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Geneva: World Health Organization; 2009. 4, Withdrawal Management. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310652/

THE INTERSTITIUM: STORIES OF ILLNESS, WELLNESS, & BEYOND

interstial space.JPG

Check out NW Narrative Medicine Collaborative’s, “The "Interstitium, a recurring storytelling event focused on health and wellness. This is the brainchild of Dr. Ben Colburn (OHSU Family Medicine Resident), whose project advisor is our very own Dr. Elizabeth Lahti. The theme this month is “The First Time,” July 24th 7:00-9:00pm at Lagunitas Community Room. Check out the link below for further details! Be sure to purchase your tickets early. Aprils event was sold out!

The Interstitum