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.

 

 

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⁽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