HPS does not present with specific clinical findings on a physical examination. The symptoms of HPS are atypical and appear with several other hepatic and non-hepatic illnesses too. However, HPS can be suspected in the presence of severe hypoxemia (characterized by partial pressure of oxygen reduced to less than 66 mm of mercury), cyanosis, spider nevi and digital clubbing [1]. Dyspnea at rest is a non-specific but obvious finding of HPS. However, this symptom is also ensued by other hepatic diseases that include anemia, ascites and muscle atrophy.

Hepatic findings that can accompany HPS include cirrhosis, pulmonary hypertension, acute liver failure and ischemic hepatitis [9].

• Hypoxemia

  Manifestations Exertional Dyspnea (see Dyspnea, [[Dyspnea]]): dyspnea is the first symptom in only 20% of cases (usually liver symptoms precede onset of dyspnea) Hypoxemia (see Hypoxemia, [[Hypoxemia]]) Orthodeoxia (see Platypnea-Orthodeoxia, [[Platypnea-Orthodeoxia [mdnxs.com]

  […] hepatopulmonary syndrome a syndrome consisting of liver disease (usually cirrhosis), hypoxemia, and the presence of intrapulmonary vascular dilatations; notable for the common presence of orthodeoxia and platypnea. hepatopulmonary syndrome arterial hypoxemia [medical-dictionary.thefreedictionary.com]

  Another important finding of HPS is pulmonary arterial hypoxemia, the definite etiology of which remains unknown. Hypoxemia in HPS is detected by measurement of the partial pressure of oxygen which is greatly reduced. [symptoma.com]

  He had full regression of hypoxemia at 3 months after a transcatheter shunt closure. These results indicate that CEPS may present in children with unexplained hypoxemia, which may lead to devastating clinical consequences. [ncbi.nlm.nih.gov]

• Asymptomatic

  The natural history, in this case, indicates that pregnancy may induce hepatopulmonary syndrome in an otherwise asymptomatic cirrhotic patient. Oxygen supplementation was the cornerstone of treatment and resulted in a favorable outcome. [ncbi.nlm.nih.gov]

• Falling

  […] and fingernails); • Cyanosis (a condition in which the lips, fingers, and toes appear blue); • Dyspnea (shortness of breath); • Platypnea (shortness of breath that is relieved when lying down and worsens when standing or sitting); and • Orthodeoxia (fall [secure.ssa.gov]

  This is the sudden fall of the partial oxygen of the patient while in standing position. Increased Nitric oxide levels. This is noted due to its vasodilator component. Esophageal varices might develop. These are dilated veins found in the esophagus. [syndromespedia.com]

  In the 13 patients without HPS the pathologically reduced SaO 2 was caused by chronic obstructive lung disease (n = 9), large volume ascites, atrial septum defect, the fall of SaO 2 with normal initial value was seen in a patient with large volume ascites [bmcgastroenterol.biomedcentral.com]

• Anemia

  […] is clinical suspicion for hepatopulmonary syndrome ≥ 15 mmHg is suggestive of HPS ≥ 20 mmHg is suggestive of HPS in patients > 64-years-old Differential Arteriovenous malformations Atrial septal defect Hepatic hydrothorax Portopulmonary hypertension Anemia [step2.medbullets.com]

  However, this symptom is also ensued by other hepatic diseases that include anemia, ascites and muscle atrophy. Hepatic findings that can accompany HPS include cirrhosis, pulmonary hypertension, acute liver failure and ischemic hepatitis. [symptoma.com]

  カルニチン欠乏症 carnitine deficiency カロリ病 Maladie de Caroli (仏), Caroli disease カロチン血症 carotenemia 川崎病 Kawasaki disease 肝アスペルギルス症 hepatic aspergillosis 肝アミロイドーシス，アミロイド肝 hepatic amyloidosis, amyloid liver 肝炎 hepatitis 肝炎後再生不良性貧血 hepatitis-associated aplastic anemia [jsge.or.jp]

  However, dyspnea is a nonspecific finding that is common in patients with advanced liver diseases because of the range of hepatic complications such as anemia, ascites, fluid retention and muscle wasting. [ghrnet.org]

  However, dyspnea is a nonspecific finding that is common in patients with advanced liver diseases because of a range of hepatic complications such as anemia, ascites, effusions, muscle wasting, malnutrition and deconditioning. [clinicaladvisor.com]

• Surgical Procedure

  APOLT is a feasible and successful surgical procedure for patients with Abernethy malformation and HPS. [ncbi.nlm.nih.gov]

  Discuss FET-PET adds 'relevant' info to pediatric cancer cases January 30, 2019 -- Thanks to its high specificity, fluoroethyl-tyrosine (FET)-PET can help confirm the success of surgical procedures performed on pediatric patients with brain and spinal [auntminnie.com]

• Dyspnea

  (see Dyspnea, [[Dyspnea]]): dyspnea is the first symptom in only 20% of cases (usually liver symptoms precede onset of dyspnea) Hypoxemia (see Hypoxemia, [[Hypoxemia]]) Orthodeoxia (see Platypnea-Orthodeoxia, [[Platypnea-Orthodeoxia]]): characteristic [mdnxs.com]

  Interestingly, six months after LT, and in the absence of dyspnea, a new CEE showed persistent passing of bubbles to the left cavities. [ncbi.nlm.nih.gov]

• Respiratory Insufficiency

  Noninvasive ventilation (NIV) was introduced, and his respiratory insufficiency promptly improved. [ncbi.nlm.nih.gov]

  They appear later than respiratory manifestations or external pancreatic insufficiency, and the present increase in the life expectancy of affected subjects has led to an increase in their frequency (1). Biliary cirrhosis is here involved. [journals.lww.com]

  Because other abnormalities, (e.g., hydrothorax, ascites) may coexist in HPS patients and contribute to respiratory insufficiency, measurement of a lowered paO 2 or SaO 2 alone is not sufficient to make the diagnosis of HPS. [bmcgastroenterol.biomedcentral.com]

  Mechanisms of impaired arterial oxygenation in patients with liver cirrhosis and severe respiratory insufficiency. Effects of indomethacin. Chest 1993 ; 103 : 500 –7. ↵ Vachiéry F, Moreau R, Hadengue A, et al. [gut.bmj.com]

• Clubbed Finger

  She had been suffered from progressive liver failure with dyspnea, clubbing fingers, and cyanosis. Preoperative arterial blood gas analysis revealed severe hypoxia (arterial O2 tension of 54.5 mmHg and O2 saturation of 84.2%). [ncbi.nlm.nih.gov]

• Jaundice

  […] platypnea increased dyspnea when upright and improves when supine weakness and fatigue Physical exam orthodeoxia decreased arterial oxygen tesion when upright and improves when supine signs of liver disease spider angiomata palmar erythema gynecomastia jaundice [step2.medbullets.com]

  […] external causes ( S00-T88 ) neoplasms ( C00-D49 ) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified ( R00 - R94 ) Diseases of the digestive system K70-K77 2019 ICD-10-CM Range K70-K77 Diseases of liver Type 1 Excludes jaundice [icd10data.com]

  壊血病 scorbutus 核黄疸 Kernikterus (独), kernicterus, nuclear jaundice 家族性アミロイドーシス familial amyloidosis 家族性アミロイドポリニューロパチー familial amyloidotic polyneuropathy 家族性LCAT欠損症 familial lecithin cholesterol acyltransferase deficiency 家族性高コレステロール血症 familial hypercholesterolemia [jsge.or.jp]

  Among the hepatic presentations of Wilson disease, cirrhosis of liver is an important member, consisting of features of hepatocellular failure such as jaundice, ascites, oedema and in extreme cases, encephalopathy. [casereports.in]

• Hepatomegaly

  ) cystic disease of liver (congenital) ( Q44.6 ) hepatic vein thrombosis ( I82.0 ) hepatomegaly NOS ( R16.0 ) pigmentary cirrhosis (of liver) ( E83.110 ) portal vein thrombosis ( I81 ) toxic liver disease ( K71.- ) Other diseases of liver Clinical [icd10data.com]

  USG revealed the presence of splenomegaly, hepatomegaly with altered echotexture and portal hypertension (PV diameter 14 mm). On Doppler study, there was no obstruction in splenic vein, portal vein and inferior vena cava. [casereports.in]

  Due to the massive hepatomegaly, and the hepatectomy was difficult. To our knowledge this is the biggest specimen from a PLD patient who was transplanted worldwide (Fig. 1). [deepdyve.com]

• Liver Fibrosis

  […] autoimmune hepatitis (one case), liver fibrosis (one case) and alcoholic cirrhosis (one case). [deepdyve.com]

  […] of portal vein thrombosis, congenital liver fibrosis and hepatosplenic schistosomiasis. 25-27 Confirming the possibility that IPVD might develop in non-cirrhotic patients with portal hypertension, HPS has been diagnosed in this population, although with [scielo.br]

• Hypertension

  Hepatopulmonary syndrome occurs in an important minority of children with cirrhosis or severe portal hypertension. [pediatrics.aappublications.org]

  Hepatopulmonary syndrome and portopulmonary hypertension are complications of portal hypertension with opposing mechanisms that can coexist. [ncbi.nlm.nih.gov]

  Liver transplantation for hepatopulmonary syndrome due to non-cirrhotic portal hypertension. Transplant Proc. 2011;43:2814–6. Article | PubMed © 2016 Sood et al. [acgcasereports.gi.org]

  Consequently, portal hypertension is not essential for manifestation of this syndrome. [scielo.org.co]

• Cyanosis

  Hence one should remain alert to the possibility of HPS while approaching a case of cyanosis. [casereports.in]

  The third patient was a 4-year-old male with a 3-year history of cyanosis and decreased exercise tolerance. He had full regression of hypoxemia at 3 months after a transcatheter shunt closure. [ncbi.nlm.nih.gov]

  The most obvious clinical finding is hypoxemia along with bluish discoloration of the skin (cyanosis). [symptoma.com]

  Examination showed evidence of hypoxemia (blood oxygen saturation on room air, 70%; on 3 L/min oxygen, 92%, with orthodeoxia), clubbing, peripheral cyanosis, petechiae, and massive splenomegaly. [acgcasereports.gi.org]

  Pulmonary signs include clubbing of the fingers, cyanosis, dyspnea, and decreased arterial oxygen concentration while in an upright position (orthodeoxia). [medical-dictionary.thefreedictionary.com]

• Thrombosis

  Key words Hepatopulmonary syndrome, portal vein thrombosis, nodular regenerative hyperplasia. [scielo.org.co]

  Preoperative portal vein thrombosis in not a contraindication for LT any more. An example for a case of an extenive portal vein thrombosis was the need for a cavo-portal hemitranspositon with good portal flow. [deepdyve.com]

  ) cystic disease of liver (congenital) ( Q44.6 ) hepatic vein thrombosis ( I82.0 ) hepatomegaly NOS ( R16.0 ) pigmentary cirrhosis (of liver) ( E83.110 ) portal vein thrombosis ( I81 ) toxic liver disease ( K71.- ) Other diseases of liver Clinical [icd10data.com]

  Two patients had non-cirrhotic portal hypertension due to nodular regenerative hyperplasia (NRH) and portal vein thrombosis of unknown origin, respectively. [bmcgastroenterol.biomedcentral.com]

• Heart Disease

  Echocardiography was performed based on the strong suspicion of congenital heart disease. There was no evidence of any congenital defect in heart. [casereports.in]

  Fallon, The Art and Science of Diagnosing and Treating Lung and Heart Disease Secondary to Liver Disease, Clinical Gastroenterology and Hepatology, 10.1016/j.cgh.2015.04.024, 13, 12, (2118-2127), (2015). M. Nagiub, R.T. Stravitz, D. Grinnan and W. [doi.org]

  The recipient, despite an elevated level of serum cholesterol (339 mg/dL), which was partially controlled by medication and diet, showed no signs of ischemic heart disease (verified by a normal coronary angiogram)(9). [deepdyve.com]

  The differential diagnosis includes idiopathic PAH, PH associated with collagen vascular disease, HIV infection, chronic thromboembolic disease, and PH resulting from left heart or chronic lung diseases [ 4, 5 ]. [err.ersjournals.com]

• Tachycardia

  Other signs include difficulty in breathing when at a resting state (dyspnea), difficulty breathing in a standing position (platypnea), orthodexia, increased heart rate (tachycardia) and development of esophageal varices. [symptoma.com]

  ECG had no abnormality except sinus tachycardia. Echocardiography was performed based on the strong suspicion of congenital heart disease. There was no evidence of any congenital defect in heart. [casereports.in]

• Palmar Erythema

  Clinically the patient may have signs and symptoms of liver disease, including gastrointestinal bleeding, esophageal varices, ascites, palmar erythema, and splenomegaly. [medical-dictionary.thefreedictionary.com]

  Physical findings: The signs of impaired liver functioning may include: • Gastrointestinal bleeding; • Esophageal varices; • Ascites; • Palmar erythema; • Spider nevi; and • Enlarged spleen (splenomegaly). [secure.ssa.gov]

  erythema gynecomastia jaundice spider nevi (spider angiomas) Imaging Transthoracic contrast echocardiography indications in patients who have evidence of impaired arterial oxygention ( e.g., increased A-a gradient) considered gold standard for detecting [step2.medbullets.com]

  Several clinical signs and symptoms characterize this syndrome; most persons will present with Liver features include gastrointestinal bleeding, esophageal varices, ascites, palmar erythema, spider nevi, and splenomegaly. [enotes.tripod.com]

  • Several clinical signs and symptoms characterize this syndrome; most persons will present with the signs and symptoms of liver disease, including gastrointestinal bleeding, esophageal varices, ascites, palmar erythema, and splenomegaly 19. [slideshare.net]

• Encephalopathy

  […] cardiac cycles after bubbles seen in right atrium --> intrapulmonary vascular dilation (if less than 3, could be due to intracardiac shunt) Pts w/ liver disease may have other lung disease that impairs gas exchange, somake sure to evaluate for: Hepatic encephalopathy [learnpicu.com]

  Hepatic Encephalopathy, Hepatorenal Syndrome, Hepatopulmonary Syndrome, and Systemic Complications of Liver Disease. In: Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, editors. [casereports.in]

  Decompensation of CLD was characterized by the occurrence of variceal bleeding, hepatic encephalopathy, infections and tense ascites as well as any other acute clinical event requiring hospitalization. [scielo.br]

  Complications of liver cirrhosis (oesophageal varices, hepatic encephalopathy and spontaneous bacterial peritonitis(SBP) were found more often in the group with HPS but only for SBP the difference approached statistical significance (p=0.002) ( Table [tropicalgastro.com]

  Exclusion Criteria: Recent chronic heavy alcohol consumption Enrollment in a clinical trial or concurrent use of another investigational drug or device therapy (i.e., outside of study treatment) during, or within 28 days of screening visit Current hepatic encephalopathy [clinicaltrials.gov]

• Stroke

  IMPLICATION OF THE HYPOTHESIS: PAVMs are one of the main causes of morbidity in patients presenting with HHT disease, owing to the risks of rupture as well as paradoxical embolism exposing to stroke and/or cerebral abscess. [ncbi.nlm.nih.gov]

  […] intelligence (AI) algorithm that analyzed free text in patient reports was better than existing risk models in predicting which symptomatic individuals were actually experiencing a transient ischemic attack, according to research published online January 17 in Stroke [auntminnie.com]

  Paradoxical embolism can occur and must be considered in any patient with HPS, given a relatively high prevalence of cerebrovascular disease, presenting with a stroke [ 77 ]. [err.ersjournals.com]

  Stroke 1991 ; 22 : 740 –5. ↵ West JB. Pulmonary pathophysiology—the essentials, 4th edn. Baltimore: Williams and Wilkins, 1990. ↵ American Thoracic Society Executive Committee. Recommended standardized procedures for pulmonary testing. [gut.bmj.com]

  Concerning the characteristics of the deceased donors, the were used livers from patients with age ranging from 6 to 66 year-old, mostly blood type A (41.2%) and 0 (32.6%), having as causes of death blunt trauma of the head (55.8%) or stroke (42.9%). [deepdyve.com]

Diagnosis of HPS is based on the presence of an obvious liver disease, moderate to severe dyspnea, severe hypoxemia and cyanosis. A number of diagnostic tests are available to confirm diagnosis in the presence of these findings.

Pulse oximetry is recommended in patients presenting with platypnea [10] whereas arterial blood gases (ABG) test should be performed in patients with severe resting dyspnea.

Contrast echocardiography is another important diagnostic tool [11] that detects abnormally increased venous blood flow. Other tests that may be helpful in confirmation of HPS include pulmonary angiography and technetium labeled albumin. However, angiography is not necessary in the absence of thromboembolism in HPS.

• Liver Biopsy

  After 5 months, a second liver biopsy revealed the amelioration of nonalcoholic steatohepatitis, which improved his respiratory condition. [ncbi.nlm.nih.gov]

  Work-up for known etiologies of chronic liver disease was negative. Liver biopsy showed maintained liver architecture with obliterative portal venopathy suggestive of non-cirrhotic portal fibrosis (NCPF). [acgcasereports.gi.org]

Treatment is based on lifestyle modification, pharmacologic therapy and in advanced cases, surgery. Once diagnosed with HPS, the patient is recommended to follow up regularly for approximately three years.

Patients with HPS are advised to restrict alcohol consumption and limit the use of hepatotoxic drugs in order to restrict further deterioration in the liver. In patients with cirrhosis, a sodium-containing diet is contraindicated to reduce fluid retention and prevent worsening of ascites. Because of the presence of hypoxemia in HPS, it is recommended to avoid cardioactive exercises that increase the oxygen demand.

No definite class of drugs is indicated for treating HPS although empiric therapy can be initiated to minimize symptoms. Excessive pulmonary vasodilation and reduced arterial oxygenation is managed by pharmacologic intervention. Patients with HPS presenting with manifestations or risk of gastroesophageal bleeding can be treated with non-selective beta adrenergic blockers [12]. Prophylactic use of antimicrobials is recommended to reduce the level of severeness in HPS [13].

The only treatment that offers complete resolution is liver transplantation. It results in eradication of hypoxemia and improved oxygenation in more than 85% of the cases [14].

HPS is a consequence of an ineffectively treated chronic liver disease. Due to this fact, the prognosis in HPS is considered to be poor. A liver transplantation has proven to result in a good clinical outcome [8].

The definite etiology of HPS is not known [3] although it has been found to develop in patients already suffering from a chronic liver disease (e.g. cirrhosis), portal hypertension, isolated portal hypertension and hepatitis [4].

The prevalence of HPS is determined on diagnostic basis and methods. The estimations vary widely from patient to patient, ranging from as low as 4% to up to 47% [5]. HPS may affect patients of all age groups.

As already described, pulmonary disease in HPS is accompanied by two common manifestations that comprise pulmonary vasodilatation and hypoxemia.

The significant elevation in concentration of the endogenous nitrous oxide (NO) leads to the development of pulmonary vasodilatation in HPS. However, the levels are normalized following liver transplantation [6]. The precise mechanism behind vascular dilatation is not fully understood yet but it is thought to result from vascular remodeling, angiogenesis, portopulmonary anastomoses and pulmonary arteriovenous shunts.

Pulmonary vasodilatation results in an increased flow of venous blood into the pulmonary veins. As a result, the normal pulmonary ventilation becomes insufficient to oxygenate the abnormally increased blood flow. This results in hypoxemia of the pulmonary blood vessels. Moreover, the diffusing capacity of carbon monoxide is impaired due to the dilation of the alveolar–capillary interface. In consequence, the equilibration of carbon monoxide with hemoglobin is proceeds only incompletely.

Several experimental studies have also indicated the association of the inflammatory mediators endothelin-1 and tumor necrosis factor-α in the pathogenesis of HPS [7].

Prevention of HPS remains unknown due to a lack of scientific data on the exact etiology of the disease.

Hepatopulmonary syndrome (HPS) is a rare disease associated with decreased arterial oxygenation (hypoxemia) in the lungs occurring as a result of pulmonary vasodilation in the presence of an already existing, advanced liver disease [1]. The most obvious clinical findings of HPS comprise liver disease, pulmonary vasodilatation and pulmonary hypoxemia. However, the presence of a hepatic dysfunction does not necessarily permit a conclusion to the severeness of HPS. Timely diagnosis and identification of the level of severeness in HPS is paramount in determining the prognosis and for planning the liver transplantation.

The pulmonary vessels in HPS are dilated and display a substantially increased blood flow. Another important finding of HPS is pulmonary arterial hypoxemia, the definite etiology of which remains unknown. Hypoxemia in HPS is detected by measurement of the partial pressure of oxygen which is greatly reduced. Another more sensitive and reliable method to determine the degree of the pulmonary oxygenation is alveolar arterial oxygen gradient. It also measures alterations in the levels of arterial carbon dioxide along with oxygen and detects respiratory alkalosis [2].

HPS can be classified into two different forms. Type I is the common form, in which vasodilatation occurs at the time of gaseous exchange. This then results in reduced oxygenation at the level of alveoli and altered ventilation. Type II HPS accounts for 10% of the total cases of HPS. This type is characterized by the presence of anatomic shunts which results in compromised gaseous exchange.

Timely diagnosis of HPS is important to prevent complications and to minimize further liver damage. Common diagnostic tests for HPS include pulse oximetry, X-ray, measurement of ABGs and pulmonary echocardiography.

The most definite and permanent treatment of HPS is liver transplantation. Pharmacological treatment is aimed at providing empirical therapy by reducing symptoms. Severe dyspnea occurring due to hypoxemia is treated with administration of supplemental oxygen.

Hepatopulmonary syndrome (HPS) is a disease affecting liver and lungs. The liver is primarily affected, which leads to an involvement of the lungs as well. The specific cause behind the combined involvement of both organs is not known yet. HPS can occur in all age groups. Early diagnosis and management of HPS can help in minimizing further deterioration and disease complications.

The classical clinical findings of HPS include liver disease, abnormally increased blood flow inside the pulmonary blood vessels (intrapulmonary vascular dilatation) and decreased oxygen levels in the blood (hypoxemia).

The exact cause of HPS remains unidentified. However, certain mechanisms that are believed to be involved in the development of HPS include

• Arteriovenous shunt following surgery
• Dysfunction of alveolar capillaries, which are the primary site for oxygenation and blood perfusion
• Inadequate ventilation
• Portal hypertension

The excessively increased product of natural vasodilator called nitrous oxide (NO) accounts for the abnormally increased intrapulmonary vascular dilatation in HPS.

The symptoms of HPS are both liver related and lung related. The most obvious clinical finding is hypoxemia along with bluish discoloration of the skin (cyanosis). Enlargement of finger tips (digital clubbing) and appearance of spider-like blood vessels on the skin (spider nevi) are typically observed in individuals with HPS. Other signs include difficulty in breathing when at a resting state (dyspnea), difficulty breathing in a standing position (platypnea), orthodexia, increased heart rate (tachycardia) and development of esophageal varices.

Diagnosis of HPS requires an evaluation of the signs and symptoms, a physical examination and a series of tests. Diagnostic tests include chest X-ray, screening of HPS with pulmonary echocardiography and measurement of arterial blood gases (ABGs). The abnormally increased blood flow in HPS can be detected by pulmonary echocardiography. The partial pressure of oxygen less than 70 mm of Hg indicates the presence of hypoxemia.

Treatment of HPS is largely based on symptomatic management and prevention of further worsening of the disease. The only definite treatment that guarantees complete cure is liver transplantation. Supportive treatment is provided with oxygen supplementation to improve ventilation. Abnormal intrapulmonary vasodilation can be managed by administration of nitrous oxide inhibitor. In the presence of chronic liver disease and cirrhosis, propanalol and nadolol are indicated in patients to prevent esophageal varices and portal hypertension.

1. Rodriguez-Roisin R, Krowka MJ, Hervé P, Fallon MB. Pulmonary-hepatic vascular disorders (PHD). Eur Respir J. 2004; 24:861-880.
2. Aller R, Moya JL, Avila S, et al. Implications of estradiol and progesterone in pulmonary vasodilatation in cirrhotic patients. J Endocrinol Invest. 2002;25:4-10.
3. Abrams GA, Jaffe CC, Hoffer PB, et al. Diagnostic utility of contrast echocardiography and lung perfusion scan in patients with hepatopulmonary syndrome. Gastroenterology. 1995;109:1283–1288.
4. Regev A, Yeshurun M, Rodriguez M, et al. Transient hepatopulmonary syndrome in a patient with acute hepatitis A. J Viral Hep. 2001;8:83–86.
5. AUKrowka MJ, Cortese DA. Hepatopulmonary syndrome. Current concepts in diagnostic and therapeutic considerations. Chest. 1994; 105(5):1528.
6. Cremona G, Higenbottam TW, Mayoral V et al. Elevated exhaled nitric oxide in patients with hepatopulmonary syndrome. Eur Respir J. 1995;8:1883–1885.
7. Rabiller A, Nunes H, Lebrec D et al. Prevention of gramnegative translocation reduces the severity of hepatopulmonary syndrome. Am J Respir Crit Care Med. 2002;166:514–517.
8. Fallon MB, Mulligan DC, Gisch RG, et al. Model for end-stage liver disease (MELD) exception for hepatopulmonary syndrome. Liver Transpl. 2006;12:105-107.
9. Fuhrmann V, Madl C, Mueller C, et al. Hepatopulmonary syndrome in patients with hypoxic hepatitis. Gastroenterology. 2006;131:69-75.
10. Abrams GA, Sanders MK, Fallon MB. Utility of pulse oximetry in the detection of arterial hypoxemia in liver transplant candidates. Liver Transpl. 2002;8:391–396.
11. Abrams GA, Jaffe CC, Hoffer PB, et al. Diagnostic utility of contrast echocardiography and lung perfusion scan in patients with hepatopulmonary syndrome. Gastroenterology 1995;109:1283-1288.
12. Garcia-Tsao G: Portal hypertension. Curr Opin Gastroenterol. 2005;21:313–322.
13. Rabiller A, Nunes H, Lebrec D, et al. Prevention of gram-negative translocation reduces the severity
    of hepatopulmonary syndrome. Am J Respir Crit Care Med. 2002;166:514–517.
14. Lange PA, Stoller JK. The Hepatopulmonary Syndrome. effect of liver transplantation. Clin Chest Med 1996;17:115–123.