Abdominal pain and dyspnea. History of hepatitis C infection and liver cirrhosis.
CT abdomen with contrast
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The liver shows cirrhotic changes manifesting as bulky left lobe and slightly irregular contours. The hepatic veins and IVC are dilated with early contrast filling and gross cardiomegaly is seen, suggesting passive hepatic venous congestion. Gallbladder oedema, associated with cirrhosis, is also seen.
Portal hypertension manifests as moderate splenomegaly (16.7cm), mild to moderate ascites with areas of partial loculation, diffuse mesenteric congestion, dilated portomesenteric venous axis and multiple peri-splenic collaterals.
Basal lung zones show consolidation in the right middle lobe as well as the laterobasal segment of the lower lobe. There are dilated tortuous vessels within the consolidated right middle lobe, suggestive of type II hepatopulmonary syndrome.
Hepatopulmonary syndrome refers to the combination of hepatic dysfunction (cirrhosis), hypoxaemia, peripheral pulmonary arterial dilatation (due to right to left microshunts). The primary condition in this patient is chronic hepatitis C infection with cirrhosis and long standing portal hypertension.
Then he developed dyspnea that was first suggested due to abdominal ascites. Triphasic CT of the liver showed peripheral dilatation of distal pulmonary arteries with nodular pattern. However, pulmonary CTA is not available to exclude pulmonary hypertension in the setting of gross cardiomegaly.