The association of digital clubbing and cirrhosis of the liver has been known since 1884. Arterial -unsaturation and cirrhosis in the absence of pulmonary disease was first noted in 1935. Abnormal behavior of hemoglobin, porto-pulmonary shunts, pulmonary arterio- venous shunts, fibrosing alveolitis and ventilation perfusion imbalance have all been proposed as possible mechanisms of the arterial unsaturation. The weight of evidence at present supports the hypothesis of pulmonary arterio-venous shunts as the major factor in the arterial unsaturation and hypoxemia associated with cirrhosis of the liver. This case emphasizes the severity of hypoxemia that can occur with liver disease and reviews the possible mechanisms involved.
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