SciELO - Scientific Electronic Library Online

 
vol.14 número4Doença celíaca revisitada índice de autoresíndice de assuntosPesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Journal

Artigo

Indicadores

Links relacionados

  • Não possue artigos similaresSimilares em SciELO

Compartilhar


Jornal Português de Gastrenterologia

versão impressa ISSN 0872-8178

J Port Gastrenterol. v.14 n.4 Lisboa set. 2007

 

Síndrome hepatopulmonar em doente com cirrose hepática: importância da sua pesquisa sistemática e impacto no prognóstico

 

R. Freire1, J. Mangualde1, A. M. Vieira1, C. Lobato1, A. L. Alves1, M. I. Cremers1, F. Augusto1, F. Caetano2, A. P. Oliveira1

 

Resumo

Introdução: A síndrome hepatopulmonar (SHP), uma complicação importante da cirrose hepática, encontra-se, provavelmente, subdiagnosticada, sendo tal facto preocupante pelas implicações prognósticas e terapêuticas que a sua identificação suscita.

Objectivos: Determinar a prevalência e impacto prognóstico da SHP em doentes com cirrose hepática.

Doentes e Métodos: Estudo prospectivo de 48 doentes com cirrose hepática, incluídos consecutivamente após observação em consulta ou internamento (sexo masculino – 77%, média etária – 59,3 anos, etiologia alcoólica – 85%, Child-Pugh A–29%, B–46%, C–25%), submetidos a gasimetria arterial e, se identificadas alterações da oxigenação, ecocardiograma de contraste. O diagnóstico de SHP foi estabelecido em presença de gradiente alvéolo-arterial de O2 aumentado e vasodilatação pulmonar. Todos os doentes foram mantidos em seguimento.

Resultados: Identificaram-se 4 doentes com SHP (8,3%). Nenhum tinha sintomas respiratórios e houve maior representação de cirrose hepática avançada (p=0,006). Com 7,8 meses de seguimento médio, a mortalidade foi significativa e independentemente mais elevada nos doentes com SHP (75% vs 13,6%, p=0,017).

Conclusões: A SHP foi relativamente frequente, particularmente na cirrose hepática avançada. Aausência de sintomas respiratórios nos casos diagnosticados, bem como a sua identificação como factor independente de prognóstico, traduzida por uma mortalidade significativamente mais elevada, aconselham à sua pesquisa sistemática.

 

Summary

Introduction: Hepatopulmonary syndrome (HPS) is an important complication of liver cirrhosis associated with worse prognosis and increased mortality. It is probably underdiagnosed, which is relevant due to the therapeutic implications associated with its identification.

Aims: To determine the prevalence and prognostic impact of HPS in patients with liver cirrhosis.

Patients and Methods: Prospective study of 48 consecutive patients with liver cirrhosis (77% male, 59 years average age, 85% alcoholic aetiology, Child-Pugh A–29%, B–46%, C–25%), evaluated by arterial blood gas analysis and, when abnormal, contrast echocardiography. The diagnosis was established if increased alveolar-arterial oxygen gradient and pulmonary vasodilatation were simultaneously present. All patients, with and without HPS, were followed.

Results: From 48 patients studied, 4 (8,3%) had HPS. Among these patients, advanced stages of cirrhosis were overrepresented and none had respiratory symptoms. With a median follow-up of 7,8 months, the mortality in the HPS subgroup was significantly and independently higher (75% versus 13,6% in the controls, p=0,017).

Conclusions: HPS is relatively frequent in patients with advanced liver cirrhosis. Symptoms are not a sensitive marker of the disease, suggesting it should be investigated systematically. It was identified as an independent prognostic factor, associated with higher mortality.

 

 

Texto Completo disponível apenas em PDF

Full text only available in PDF format

 

 

BIBLIOGRAFIA

1. Kennedy TC, Knudson RJ. Exercise-aggravated hypoxemia and orthodeoxia in cirrhosis. Chest 1977; 72: 305-9.        [ Links ]

2. Krowka MJ, Cortese DA. Pulmonary aspects of liver disease and liver transplantation. Clin Chest Med 1989; 10: 593-616.

3. Rodriguez-Roisin R, Wagner PD. Clinical relevance of ventilationperfusion inequality determined by inert gas elimination. Eur Respir J 1989; 3: 469-82.

4. Zhang M, Luo B, Chen SJ, Abrams GA, Fallon MB. Endothelin-1 stimulation of endothelial nitric oxide synthase in the pathogenesis of hepatopulmonary syndrome. Am J Physiol 1999; 277: G944-52.

5. Nunes H, Lebrec D, Mazmanian M, Capron F, Heller J, Tazi KA. Role of nitric oxide in hepatopulmonary syndrome in cirrhotic rats. Am J Respir Crit Care Med 2001; 164: 879-85.

6. Lange PA, Stoller JK. The hepatopulmonary syndrome. Ann Intern Med 1995; 122(7): 521-9.

7. Agusti AGN, Roca J, Bosch J, Rodriguez-Roisin R. The lung in patients with cirrhosis. J Hepatol 1990; 10: 251-7.

8. Rodriguez-Roisin R, Agusti AGN, Roca J. Pulmonary function and liver disease. Current Opinion Gastroenterol 1988; 4: 609-14.

9. Melot C, Naeije R, Dechamps P, Hallemans R, Lejeune P. Pulmonary and extrapulmonary contributors to hypoxemia in liver cirrhosis. Am Rev Respir Dis 1989; 139: 631-40.

10. Eriksson LS. Hypoxemia in patients with liver cirrhosis. Acta Gastroenterol Belg 1990; 53: 209-15.

11. Abrams GA, Jaffe CC, Hoffer PB, Binder HJ. Diagnostic utility of contrast echocardiography and lung perfusion scan in patients with hepatopulmonary syndrome. Gastroenterology 1995; 109: 1283-8.

12. Martinez GP, Barbera JA, Visa J, Rimola A, Pare JC, Roca J, Hepatopulmonary syndrome in candidates for liver transplantation. J Hepatol 2001; 34: 651-7.

13. Lima BL, Franca AB, Pazin-Filho A, Araújo WM, Martinez JA, Maciel BC. Frequency, clinical characteristics and respiratory parameters of hepatopulmonary syndrome. Mayo Clin Proc 2004; 79(1): 42-8.

14. Schenk P, Schoniger-Hekele M, Fuhrman V, Madl C, Silberhumer G, Muller C. Prognostic significance of the hepatopulmonary syndrome in patients with cirrhosis. Gastroenterology 2003; 125: 1042-52.

15. Schenk P, Fuhrman V, Madl C, Funk G, Lehr S, Kandel O. Hepatopulmonary syndrome: prevalence and predictive values of various cut offs for arterial oxygenation and their clinical consequences. Gut 2002; 51: 853-9.

16. Krowka M, Wiseman G, Burnett O, Spivey J, Therneau T, Porayko M, et al. Hepatopulmonary syndrome: A prospective study of the relationships between severity of liver disease, PaO2 response to 100% oxygen, and brain uptake after 99mTc MAA lung scanning. Chest 2000; 118: 615-24.

17. Arguedas MR, Abrams GA, Krowka MJ, Fallon MB. Prospective evaluation of outcomes and predictors of mortality in patients with hepatopulmonary syndrome undergoing liver transplantation. Hepatology 2003; 1: 192-7.

18. Fallon MB, Abrams GA. Hepatopulmonary Syndrome. Curr Gastroenterol Rep 2000;2: 40-5.

19. Krowka MJ. Hepatopulmonary syndrome: recent literature (1997 to 1999) and implications for liver transplantation. Liver Transpl 2000; 6: S31-5.

20. Rodriguez-Roisin R, Agusti GN, Roca J. The hepatopulmonary syndrome: new name, old complexities. Thorax 1992; 47: 897-902

21. Herve P, Lebrec D, Brenot F, Simonneau G, Humbert M, Sitbon O. Pulmonary vascular disorders in portal hypertension. Eur Respir J 1998;11: 1153-66.

22. Whyte M, Hughes J, Peters A, Ussov W, Patel S, Burroughs A. Analysis of intrapulmonary right to left shunt in hepatopulmonary syndrome. J Hepatol 1998;29: 85-93.

23. Krowka MJ, Dickson ER, Cortese DA. Hepatopulmonary Syndrome: clinical observations and lack of therapeutic response to somatostatin analogue. Chest 1993; 104(2): 515-21.

24. Hunt K, Kawut S, Rosenthal L, LaPointe-Rudow D, Emond J, Brown R. (Re?)Defining hepatopulmonary syndrome in patients listed for liver transplantation (abstract). Hepatology 2002; 36: 188.

25. Krowka MJ, Cortese DA. Hepatopulmonary Syndrome. Current concepts in diagnostic and therapeutic considerations. Chest 1994; 105: 1528-37.

26. Robin ED, Horn B, Goris ML, Theodore J, Kessel AV, Mazoub J. Detection, quantitation and pathophysiology of lung spiders. Trans Assoc Am Physicians 1975; 88: 202-16.

27. Hind CRK, Wong CM. Detection of pulmonary arteriovenous fistulae in patients with cirrhosis by contrast two-dimensional echocardiography. Gut 1981; 22: 1042-5.

28. Abrams GA, Nanda Nc, Dubovsky EV, Krowka MJ, Fallon MB. Use of macroaggregated albumin lung perfusion scan to diagnose hepatopulmonary syndrome: a new approach. Gastroenterology 1998; 114: 305-10.

29. Krowka MJ, Porayko MK, Plevak DJ, Pappas SC, Steers JL, Krom RAF, et al. Hepatopulmonary syndrome with progressive hypoxemia as an indication for liver transplantation: case reports and literature review. Mayo Clin Proc 1997; 72: 44-53.

30. Paramesh AS, Husain SZ, Shneider B, Guller J, Tkat I, Gondolesi GE, et al. Improvement of hepatopulmonary syndrome after transjugular intrahepatic portosystemic shunt: case report and review ofthe literature. Pediatr Transplant 2003; 7: 157-62.

31. Em: http://www.unos.org (Policy 3.6.4.5.1, consultado em 30/6/2006).

32. Mellemgaard K. The alveolar-arterial oxygen difference: its size and components in normal man. Acta Physiol Scand 1966; 67: 10-20.

33. Global Initiative for Chronic Obstructive Lung Disease (GOLD), World Health Organization (WHO), National Heart, Lung and Blood Institute (NHLBI). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda (MD): Global Initiative for Chronic Obstructive Lung Disease, World Health Organization, National Heart, Lung and Blood Institute; 2005.

34. The Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis. 6th ed. Boston, Mass: Little Brown; 1964.

35. Evans LT, Kim WR, Poterucha JJ, Kamath PS. Spontaneous bacterial peritonitis in asymptomatic outpatients with cirrhotic ascites. Hepatology 2003; 37: 897-901.

36. Perez-Ayuso RM, Arroyo V, Planas R, Gaya J, Bory F, Rimola A, et al. Randomized comparative study of efficacy of furosemide vs. spironolactone in nonazotemic cirrhosis with ascites. Gastroenterology 1983; 84: 961-8.

37. Stanley MM, Ochi S, Lee KK, Nemchausky BA, Greenlee HB, Allen JI, et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. N Engl J Med 1989; 321: 1632-8.

38. Gines A, Escorsell A, Gines P, Salo J, Gimenez W, Inglada L, et al. Incidence, predictive factors, and prognosis of the hepatorrenal syndrome in cirrhosis with ascites. Gastroenterology 1993; 105: 229-36.

39. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and Esophageal varices: a prospective multicenter study. N Engl J Med 1988; 319: 983-9.

40. Groszmann RJ, Bosch J, Grace ND, Conn HO, Garcia-Tsao G, Navasa M, et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990; 99: 1401-7.

 

 

(1) Serviço de Gastrenterologia

(2) Serviço de Cardiologia

Centro Hospitalar de Setúbal, Hospital de S. Bernardo E.P.E., Setúbal, Portugal

 

Correspondência:

Ricardo Freire

Serviço de Gastrenterologia

Hospital de São Bernardo

Rua Camilo Castelo Branco

2910 – Setúbal

Tel.: 265549070

e-mail: ricardofreire@netvisao.pt

 

Recebido para publicação: 19/10/2006

Aceite para publicação: 17/09/2007