Hepatopulmonary Syndrome Diagnosis in the ICU: The Relevance of Bedside Contrast Saline Echocardiography.

Hepatopulmonary syndrome (HPS) is an underdiagnosed complication of chronic liver disease (CLD) characterised by the presence of hypoxaemia due to intrapulmonary vascular dilatations. We present two cases of HPS diagnosed during their stay in the ICU. Both patients had a medical history of alcoholic CLD with portal hypertension (PH). The first patient was transferred to the ICU for acute hypoxic respiratory failure (AHRF) due to decompensated cirrhosis with large-volume hydrothorax and diagnosis of acute-on-chronic liver failure (ACLF) grade 2. The presence of orthodeoxia, an alveolar-arterial oxygen gradient (O2 A-a grad) of 27 mmHg and positive contrast saline echocardiography confirmed the HPS diagnosis. The second patient was transferred to our general ICU from the surgical ward where he was initially admitted with mild AHRF due to polytrauma conditioning left side rib fractures and a small contusion in the left inferior lobe. Upon ICU admission, he was diagnosed with septic shock (nosocomial pneumonia as the primary site of infection) and required invasive mechanical ventilation. During the initial period of his ICU stay, although an improvement in multiple organ dysfunction was observed, severe AHRF persisted. Moreover, O2 A-a grad of 30 mmHg and positive bedside contrast saline echocardiography confirmed the HPS diagnosis. In this study, we discuss the diagnostic approach of HPS and the increasing relevance of contrast saline echocardiography at the bedside, particularly in critically ill patients. The performance of this technique by trained intensivists at the bedside in the ICU minimises critical moments, such as the time required for intra-hospital transport of patients for complementary examinations, considering they have severe ventilatory compromise, thereby allowing HPS diagnosis with high sensitivity.

Evaluation Of Congestion Levels in Septic Patients Admitted to Critical Care Units with a Combined Venous Excess-Lung Ultrasound Score (VExLUS) - a Research Protocol.

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection with a high mortality rate. Septic shock is a subset of sepsis with manifest circulatory dysfunction (use of vasopressors and persistent elevation of lactic acid) . As stated in literature, in addition to the use of empiric antibiotics and control of the infectious focus, intravenous fluid therapy is an essential intervention to promote hemodynamic stabilization. However, the literature also describes harmful outcomes related to fluid overload. Hemodynamic management in critically ill patients has traditionally focused on maintaining adequate cardiac output and arterial blood pressure by relying on fluid administration and/or vasopressor/inotropic support. However, organ perfusion is affected by other important factors, such as venous pressure, which can be overlooked. The evaluation of lung congestion with point of care ultrasound (POCUS), as a signal of extravascular fluid, and, more recently, a venous excess Doppler ultrasound (VExUS) grading system, are parameters for the assessment of the fluid status of the patient and organ congestion. Our main hypothesis is that adding a modified lung ultrasound score to the VExUS protocol could provide higher sensitivity and earlier identification of fluid overload, guiding the clinician in the decision of fluid administration in patients with sepsis.

Colangiocarcinoma en un paciente con enfermedad de Wilson / Cholangiocarcinoma in a patient with Wilson´s disease

The incidence of hepatobiliary malignancies, and especially intrahepatic cholangiocarcinoma (ICC), for patients with Wilson’s disease (WD), is very low, even for cirrhotic patients. It has been suggested that hepatobiliary carcinomas are less frequent in Wilson’s disease (WD) than in liver diseases of other etiology. However, the protective role of copper against malignancies is debated. Only a few cases of cholangiocarcinoma (CCC) in WD have been published. Here we report a case of a 39-year-old female, WD diagnosed at 19-year-old based on low ceruloplasmin level, low serum copper, and increased urinary copper. She was followed up and treated with chelating agents throughout nineteen years, after this asymptomatic period she reported abdominal pain. MRI showed hepatic lesions not suggestive of hemangiomas and a nodular lesion of 15mm in the right lobe. Liver biopsy was made, with non-specific fibrosis; negative for malignancy. Few months later she was admitted in the hospital because of rapidly development of epigastric/right hypochondrium abdominal pain with four days of evolution, anorexia and asthenia. Biopsy revealed cholangiocarcinoma as the primary tumor confirmed by strong CK7 and CK20 positivity. The curiosity of the presented case is the very rapid development of CCC despite continuous chelating agent therapy. (AU)