Breathless on Standing: Hepatopulmonary Syndrome in Chronic Liver Disease

In patients with chronic liver disease, positional dyspnea (platypnea) and desaturation (orthodeoxia) should prompt immediate evaluation. Although the differential diagnosis includes many cardiopulmonary disorders, platypnea-orthodeoxia raises concern for right-to-left shunting and gravity-dependent ventilation–perfusion ratio mismatch, particularly hepatopulmonary syndrome. This condition carries high mortality and requires prompt evaluation for liver transplantation. We present a patient with chronic untreated hepatitis C who developed significant platypnea and orthodeoxia. Work-up revealed a markedly elevated alveolar-arterial gradient, and contrast-enhanced (agitated saline) echocardiography demonstrated substantial intrapulmonary shunting, confirming the diagnosis.