Hepatopulmonary syndrome physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for liver disease findings such as [[jaundice]], [[palmar erythema]], [[Spider angioma|spider angiomata]], [[Gynecomastia|gynaecomastia]] ,[[abdominal distension]], [[caput medusae]], [[splenomegaly]] either with or without sign and symptoms of [[hypoxemia]] such as [[cyanosis]] and [[clubbing]].The presence of [[platypnea]] on physical examination is highly suggestive of hepatopulmonary syndrome. | |||
The presence of [ | |||
==Physical Examination== | ==Physical Examination== | ||
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for liver disease findings such as [[jaundice]], [[palmar erythema]], [[Spider angioma|spider angiomata]], [[Gynecomastia|gynaecomastia]] ,[[abdominal distension]], [[caput medusae]], [[splenomegaly]] either with or without sign and symptoms of [[hypoxemia]] such as [[cyanosis]] and [[clubbing]].The presence of [[platypnea]] on physical examination is highly suggestive of hepatopulmonary syndrome.<ref name="pmid14708947">Lima BL, França AV, Pazin-Filho A, Araújo WM, Martinez JA, Maciel BC et al. (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14708947 Frequency, clinical characteristics, and respiratory parameters of hepatopulmonary syndrome.] ''Mayo Clin Proc'' 79 (1):42-8. [http://dx.doi.org/10.4065/79.1.42 DOI:10.4065/79.1.42] PMID: [https://pubmed.gov/14708947 14708947]</ref> | |||
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for [ | |||
The presence of [ | |||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
*Patients with hepatopulmonary syndrome | *Patients with hepatopulmonary syndrome may appear either normal, cyanotic, jaundiced, or ill, depending on the severity of their liver disease and HPS stage.<ref name="pmid18509123">Rodríguez-Roisin R, Krowka MJ (2008) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18509123 Hepatopulmonary syndrome--a liver-induced lung vascular disorder.] ''N Engl J Med'' 358 (22):2378-87. [http://dx.doi.org/10.1056/NEJMra0707185 DOI:10.1056/NEJMra0707185] PMID: [https://pubmed.gov/18509123 18509123]</ref><ref name="pmid11003635">Fallon MB, Abrams GA (2000) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11003635 Pulmonary dysfunction in chronic liver disease.] ''Hepatology'' 32 (4 Pt 1):859-65. [http://dx.doi.org/10.1053/jhep.2000.7519 DOI:10.1053/jhep.2000.7519] PMID: [https://pubmed.gov/11003635 11003635]</ref><ref name="pmid14762853">Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C et al. (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14762853 Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database.] ''Liver Transpl'' 10 (2):174-82. [http://dx.doi.org/10.1002/lt.20016 DOI:10.1002/lt.20016] PMID: [https://pubmed.gov/14762853 14762853]</ref><ref name="pmid891282">Kennedy TC, Knudson RJ (1977) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=891282 Exercise-aggravated hypoxemia and orthodeoxia in cirrhosis.] ''Chest'' 72 (3):305-9. [http://dx.doi.org/10.1378/chest.72.3.305 DOI:10.1378/chest.72.3.305] PMID: [https://pubmed.gov/891282 891282]</ref><ref name="pmid27326810">Krowka MJ, Fallon MB, Kawut SM, Fuhrmann V, Heimbach JK, Ramsay MA et al. (2016) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=27326810 International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension.] ''Transplantation'' 100 (7):1440-52. [http://dx.doi.org/10.1097/TP.0000000000001229 DOI:10.1097/TP.0000000000001229] PMID: [https://pubmed.gov/27326810 27326810]</ref><ref name="pmid8101797">Krowka MJ, Dickson ER, Cortese DA (1993) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8101797 Hepatopulmonary syndrome. Clinical observations and lack of therapeutic response to somatostatin analogue.] ''Chest'' 104 (2):515-21. [http://dx.doi.org/10.1378/chest.104.2.515 DOI:10.1378/chest.104.2.515] PMID: [https://pubmed.gov/8101797 8101797]</ref><ref name="pmid15828054">Swanson KL, Wiesner RH, Krowka MJ (2005) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15828054 Natural history of hepatopulmonary syndrome: Impact of liver transplantation.] ''Hepatology'' 41 (5):1122-9. [http://dx.doi.org/10.1002/hep.20658 DOI:10.1002/hep.20658] PMID: [https://pubmed.gov/15828054 15828054]</ref><ref name="pmid1465744">Rodríguez-Roisin R, Agustí AG, Roca J (1992) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1465744 The hepatopulmonary syndrome: new name, old complexities.] ''Thorax'' 47 (11):897-902. [http://dx.doi.org/10.1136/thx.47.11.897 DOI:10.1136/thx.47.11.897] PMID: [https://pubmed.gov/1465744 1465744]</ref> | ||
===Vital Signs=== | ===Vital Signs=== | ||
| Line 40: | Line 16: | ||
*Platypnea (symptom) | *Platypnea (symptom) | ||
*Orthodeoxia (sign), a drop of 4mmHg in PaO2 or, 5% in saturation when moving from the supine to the standing position. | *Orthodeoxia (sign), a drop of 4mmHg in PaO2 or, 5% in saturation when moving from the supine to the standing position. | ||
{{#ev:youtube|1wEWw2cdXn0}} | |||
===Skin=== | ===Skin=== | ||
* Skin examination of patients with hepatopulmonary syndrome moight reveal, spider angiomata . (likelihood of HPS 21%). | * Skin examination of patients with hepatopulmonary syndrome moight reveal, spider angiomata . (likelihood of HPS 21%). | ||
*[[Cyanosis]] | *[[Cyanosis]] | ||
*[[Jaundice]] | |||
*[[Palmar erythema]] | |||
*[[Spider angioma|Spider angiomata]] | |||
<br /> | |||
{{#ev:youtube|RT-8OzD9j00}} | |||
===HEENT === | |||
* HEENT examination of patients with hepatopulmonary syndrome might be either normal, show sign and symptoms of hypoxemia such as cyanotic mucosal membranes, or findings of liver disease such as: | |||
:* Thinning of hair on the scalp due to [[hyperestrogenism]] | |||
* | :* '''[[Kayser-Fleischer ring]]s in [[Patient|patients]] with [[Wilson's disease]]<ref name="pmid28573989">{{cite journal |vauthors=Sridhar MS, Rangaraju A, Anbarasu K, Reddy SP, Daga S, Jayalakshmi S, Shaik B |title=Evaluation of Kayser-Fleischer ring in Wilson disease by anterior segment optical coherence tomography |journal=Indian J Ophthalmol |volume=65 |issue=5 |pages=354–357 |year=2017 |pmid=28573989 |pmc=5565897 |doi=10.4103/ijo.IJO_400_16 |url=}}</ref>''' | ||
:*[[Fetor hepaticus]] | |||
* | |||
* [[ | |||
===Neck=== | ===Neck=== | ||
* Neck examination of patients with hepatopulmonary syndrome is usually normal. | * Neck examination of patients with hepatopulmonary syndrome is usually normal. | ||
*[[Parotid gland]] enlargement might e present as a cirrhosis related finding. | |||
*[[ | *The following might be present in the differential diagnosis of HPS but neither role out nor role in HPS diagnosis. | ||
* | :*[[Jugular venous distension]] | ||
*[[ | :*[[Hepatojugular reflux]] | ||
*[[Hepatojugular reflux]] | |||
===Lungs=== | ===Lungs=== | ||
* Pulmonary examination of patients with hepatopulmonary syndrome | * Pulmonary examination of patients with hepatopulmonary syndrome might be normal. | ||
* | * Sometimes, in patients with severe [[ascites]]. | ||
*Distant and decreased breath sounds in pulmonary bases. | |||
* | |||
===Heart=== | ===Heart=== | ||
* Cardiovascular examination of patients with hepatopulmonary syndrome | * Cardiovascular examination of patients with hepatopulmonary syndrome might be normal. | ||
* | *Because Cirrhosis complicated with HPS is a high cardiac output condition the following might be present: | ||
*[[Heave]] / [[thrill]] | *[[Heave]] / [[thrill]] | ||
*[[Heart sounds#Third heart sound S3|S3]] | *[[Heart sounds#Third heart sound S3|S3]] | ||
*[[Heart sounds#Fourth heart sound S4|S4]] | *[[Heart sounds#Fourth heart sound S4|S4]] | ||
*[[Heart sounds#Summation Gallop|Gallops]] | *[[Heart sounds#Summation Gallop|Gallops]] | ||
* | *[[Friction rub]] (due to cirrhosis complications) | ||
===Abdomen=== | ===Abdomen=== | ||
* Abdominal examination of patients with hepatopulmonary syndrome | * Abdominal examination of patients with hepatopulmonary syndrome could be normal. | ||
*[[Abdominal distension]] | *With respect to the cirrhosis severity and other complications rather than HPS, the followings might be present: | ||
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant | *[[Abdominal distension]] | ||
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant in [[SBP|'''spontaneous bacterial peritonitis (SBP)''']] | |||
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant | *A palpable abdominal mass in the right/left upper/lower abdominal quadrant in [[Hepatocellular carcinoma|'''hepatocellular carcinoma''']] | ||
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]] | *[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]] | ||
===Back=== | ===Back=== | ||
* Back examination of patients with hepatopulmonary syndrome is usually normal. | * Back examination of patients with hepatopulmonary syndrome is usually normal. | ||
===Genitourinary=== | ===Genitourinary=== | ||
* Genitourinary examination of patients with hepatopulmonary syndrome is usually normal. | * Genitourinary examination of patients with hepatopulmonary syndrome is usually normal. | ||
*[[Gynecomastia|Gynaecomastia]] | |||
* | |||
===Neuromuscular=== | ===Neuromuscular=== | ||
* Neuromuscular examination of patients with hepatopulmonary syndrome is usually normal. | * Neuromuscular examination of patients with hepatopulmonary syndrome is usually normal. | ||
*in the presence of severely complicated cirrhosis with or without HPS, [[asterixis]], cognitive disturbance, loss of consciousness, [[coma]] and death is possible. | |||
* | |||
* Altered mental status | *Altered mental status | ||
* | * Bilateral tremor (asterixis) | ||
===Extremities=== | ===Extremities=== | ||
| Line 154: | Line 85: | ||
*[[Clubbing]] | *[[Clubbing]] | ||
*[[Cyanosis]] | *[[Cyanosis]] | ||
*Palmar erythema (cirrhosis sign) | *[[Palmar erythema]] (cirrhosis sign) | ||
*Edema (due to | *Edema (due to decreased albumin production in a malfunctioning liver) | ||
==References== | ==References== | ||
| Line 162: | Line 93: | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category: | [[Category:Surgery]] | ||
[[Category:Medicine]] | |||
[[Category:Pulmonology]] | |||
[[Category:Cardiology]] | |||
[[Category:Gastroentrology]] | |||
[[Category:Up-To-Date]] | |||
Latest revision as of 17:58, 6 September 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for liver disease findings such as jaundice, palmar erythema, spider angiomata, gynaecomastia ,abdominal distension, caput medusae, splenomegaly either with or without sign and symptoms of hypoxemia such as cyanosis and clubbing.The presence of platypnea on physical examination is highly suggestive of hepatopulmonary syndrome.
Physical Examination
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for liver disease findings such as jaundice, palmar erythema, spider angiomata, gynaecomastia ,abdominal distension, caput medusae, splenomegaly either with or without sign and symptoms of hypoxemia such as cyanosis and clubbing.The presence of platypnea on physical examination is highly suggestive of hepatopulmonary syndrome.[1]
Appearance of the Patient
- Patients with hepatopulmonary syndrome may appear either normal, cyanotic, jaundiced, or ill, depending on the severity of their liver disease and HPS stage.[2][3][4][5][6][7][8][9]
Vital Signs
- Platypnea (symptom)
- Orthodeoxia (sign), a drop of 4mmHg in PaO2 or, 5% in saturation when moving from the supine to the standing position.
{{#ev:youtube|1wEWw2cdXn0}}
Skin
- Skin examination of patients with hepatopulmonary syndrome moight reveal, spider angiomata . (likelihood of HPS 21%).
{{#ev:youtube|RT-8OzD9j00}}
HEENT
- HEENT examination of patients with hepatopulmonary syndrome might be either normal, show sign and symptoms of hypoxemia such as cyanotic mucosal membranes, or findings of liver disease such as:
- Thinning of hair on the scalp due to hyperestrogenism
- Kayser-Fleischer rings in patients with Wilson's disease[10]
- Fetor hepaticus
Neck
- Neck examination of patients with hepatopulmonary syndrome is usually normal.
- Parotid gland enlargement might e present as a cirrhosis related finding.
- The following might be present in the differential diagnosis of HPS but neither role out nor role in HPS diagnosis.
Lungs
- Pulmonary examination of patients with hepatopulmonary syndrome might be normal.
- Sometimes, in patients with severe ascites.
- Distant and decreased breath sounds in pulmonary bases.
Heart
- Cardiovascular examination of patients with hepatopulmonary syndrome might be normal.
- Because Cirrhosis complicated with HPS is a high cardiac output condition the following might be present:
- Heave / thrill
- S3
- S4
- Gallops
- Friction rub (due to cirrhosis complications)
Abdomen
- Abdominal examination of patients with hepatopulmonary syndrome could be normal.
- With respect to the cirrhosis severity and other complications rather than HPS, the followings might be present:
- Abdominal distension
- Abdominal tenderness in the right/left upper/lower abdominal quadrant in spontaneous bacterial peritonitis (SBP)
- A palpable abdominal mass in the right/left upper/lower abdominal quadrant in hepatocellular carcinoma
- Hepatomegaly / splenomegaly / hepatosplenomegaly
Back
- Back examination of patients with hepatopulmonary syndrome is usually normal.
Genitourinary
- Genitourinary examination of patients with hepatopulmonary syndrome is usually normal.
- Gynaecomastia
Neuromuscular
- Neuromuscular examination of patients with hepatopulmonary syndrome is usually normal.
- in the presence of severely complicated cirrhosis with or without HPS, asterixis, cognitive disturbance, loss of consciousness, coma and death is possible.
- Altered mental status
- Bilateral tremor (asterixis)
Extremities
- Clubbing
- Cyanosis
- Palmar erythema (cirrhosis sign)
- Edema (due to decreased albumin production in a malfunctioning liver)
References
- ↑ Lima BL, França AV, Pazin-Filho A, Araújo WM, Martinez JA, Maciel BC et al. (2004) Frequency, clinical characteristics, and respiratory parameters of hepatopulmonary syndrome. Mayo Clin Proc 79 (1):42-8. DOI:10.4065/79.1.42 PMID: 14708947
- ↑ Rodríguez-Roisin R, Krowka MJ (2008) Hepatopulmonary syndrome--a liver-induced lung vascular disorder. N Engl J Med 358 (22):2378-87. DOI:10.1056/NEJMra0707185 PMID: 18509123
- ↑ Fallon MB, Abrams GA (2000) Pulmonary dysfunction in chronic liver disease. Hepatology 32 (4 Pt 1):859-65. DOI:10.1053/jhep.2000.7519 PMID: 11003635
- ↑ Krowka MJ, Mandell MS, Ramsay MA, Kawut SM, Fallon MB, Manzarbeitia C et al. (2004) Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl 10 (2):174-82. DOI:10.1002/lt.20016 PMID: 14762853
- ↑ Kennedy TC, Knudson RJ (1977) Exercise-aggravated hypoxemia and orthodeoxia in cirrhosis. Chest 72 (3):305-9. DOI:10.1378/chest.72.3.305 PMID: 891282
- ↑ Krowka MJ, Fallon MB, Kawut SM, Fuhrmann V, Heimbach JK, Ramsay MA et al. (2016) International Liver Transplant Society Practice Guidelines: Diagnosis and Management of Hepatopulmonary Syndrome and Portopulmonary Hypertension. Transplantation 100 (7):1440-52. DOI:10.1097/TP.0000000000001229 PMID: 27326810
- ↑ Krowka MJ, Dickson ER, Cortese DA (1993) Hepatopulmonary syndrome. Clinical observations and lack of therapeutic response to somatostatin analogue. Chest 104 (2):515-21. DOI:10.1378/chest.104.2.515 PMID: 8101797
- ↑ Swanson KL, Wiesner RH, Krowka MJ (2005) Natural history of hepatopulmonary syndrome: Impact of liver transplantation. Hepatology 41 (5):1122-9. DOI:10.1002/hep.20658 PMID: 15828054
- ↑ Rodríguez-Roisin R, Agustí AG, Roca J (1992) The hepatopulmonary syndrome: new name, old complexities. Thorax 47 (11):897-902. DOI:10.1136/thx.47.11.897 PMID: 1465744
- ↑ Sridhar MS, Rangaraju A, Anbarasu K, Reddy SP, Daga S, Jayalakshmi S, Shaik B (2017). "Evaluation of Kayser-Fleischer ring in Wilson disease by anterior segment optical coherence tomography". Indian J Ophthalmol. 65 (5): 354–357. doi:10.4103/ijo.IJO_400_16. PMC 5565897. PMID 28573989.