The Art and Science of Diagnosing and Treating Lung and Heart Disease Secondary to Liver Disease

Abstract

Patients with chronic liver disease are at risk of extra-hepatic complications related to cirrhosis and portal hypertension, as well organ-specific complications of certain liver diseases. These complications can compromise quality-of-life, while also increasing morbidity and mortality pre- and post-liver transplantation. Patients with chronic liver disease are at risk for pulmonary complications of hepaotpulmonary syndrome and portopulmonary syndrome; the major cardiac complication falls under the general concept of the cirrhotic cardiomyopathy, which can affect systolic and diastolic function, as well as cardiac conduction. In addition, patients with certain diseases are at risk of lung and/or cardiac complications that are specific to the primary disease (i.e., emphysema in alpha-1-antitrypsin deficiency) or occur with increased incidence in certain conditions (i.e., ischemic heart disease associated with non-alcoholic steatohepatitis. This section will focus on the epidemiology, clinical presentation, pathogenesis, treatment options, and role of transplantation for lung and heart diseases secondary to liver disease, while also highlighting select liver diseases that directly affect the lungs and hearts.

Cardiopulmonary examination

“…There is limited correlation between the severity of liver disease measured by Child‐Turcotte‐Pugh classification (A, B, and C) or Model for End‐Stage Liver Disease score and cardiopulmonary examination findings. One frequently documents the presence of severe hepatopulmonary syndrome (HPS) or portopulmonary hypertension (POPH) in patients with Child A disease or low Model for End‐Stage Liver Disease score (<10) …”

“…The cardiopulmonary examination conducted in patients with liver disease is undertaken for obvious clinical reasons, but importantly to identify and manage problems that may significantly affect liver transplant considerations . This brief overview will address key cardiac and pulmonary examination findings and emphasize findings for the clinician leading to diagnoses “not to be missed.” Although use of the stethoscope seems to have fallen out of favor with the dominance of echocardiography and chest computed tomography, it remains a valuable tool that does slow a personal “connection” with the examiner and patient.…”

Hepatobiliary Quiz (Answers)—16 (2015)

“…Though the mechanisms of myocardial stiffness and remodeling are unclear, it occurs more commonly in patients who have more advanced liver disease with higher MELD and Child-Pugh scores. [39][40][41] Patients with cirrhosis are also more likely to have a prolonged QT interval, independent of other known risk factors for this condition. 39,42,43 Hereditary hemochromatosis often involves the heart, and can lead to congestive heart failure, conduction abnormalities, and, rarely, a restrictive cardiomyopathy.…”

“…Shunting occurs due to precapillary and postcapillary dilatation of the pulmonary microvasculature, as well as by the formation of new blood vessels. 39,47,48 HPS may occur in at least 10% of all patients with cirrhosis and portal hypertension, and in one third of patients evaluated for liver transplantation. [47][48][49] HPS is a diagnosis of exclusion, and none of the teats are specific for its diagnosis.…”

Cardiac function, A key component in evaluation for liver transplant

“…Nonhepatic organ abnormalities that can complicate cirrhosis can adversely impact a prognosis. Hepatopulmonary syndrome and portopulmonary hypertension are 2 examples . Cardiac dysfunction has also been described in cirrhosis as cirrhotic cardiomyopathy .…”