Abstract
A case of liver cirrhosis with cyanosis and fingerclubbing is reported. A sixty-year-old female entered our hospital because of exertional dyspnea and cyanotic lips. She was not in acute distress and not dyspneic at rest. Respiratory rate was 22 per minute. Lips and nail beds were cyanotic and fingers were clubbed. Auscultation revealed no significant rale and no significant cardiac murmurs. The liver was enlarged and hard. There were some vascular spiders on the anterior and posterior chest walls.
Chest X-ray films showed fine reticular shadows in the lower lung fields.
From liver scintigram and liver biopsy, a diagnosis of liver cirrhosis was made.
Arterial blood gas analysis showed marked hypoxemia (PO2 46.3mmHg and SO2 84.8%) and alveolar hyperventilation (PCO2 24.4mmHg).
The cause of cyanosis was investigated in the following way.
1) Intracardiac shunt was denied on the basis of physical examination and indicator dilution studies.
2) Measurement of lung volumes and ventilatory functions, closing volume and flow-volume analysis did not reveal any lesions which might be the cause of cyanosis. Although the diffusing capacity (DLCO) was moderately decreased to 60% of the predicted value, this decrease was not sufficient to explain the hypoxemia already present at rest.
3) There was no abnormal Hb. 2-3 DPG in RBC was slightly increased. However, comparison of the O2-Hb saturation values obtained by Van-Slyke manometry and corrected for pH differences with electrochemically measured O2 tension (four steps) showed no rightward shift of O2-Hb dissociation curve of the patient's own blood.
4) Pulmonary arteriogram with the injection of contrast material into the right atrium did not demonstrate the presence of arteriovenous fistula and pulmonary perfusion scanning by 99mTc-MAA did not demonstrate any perfusion defect.
5) After 100% oxygen was administered for 20 minutes through a two-way nonreturn valve, arterial blood was drawn and analysed. From Berggren's standard formula, venous admixture was calculated approximately 22% of the cardiac output.
These results suggest that the cause of cyanosis in this patient is intrapulmonary venous admixture which seems to be related to liver cirrhosis. The intrapulmonary venous admixture was also the cause of cyanosis of other cases reported up to this time.
