Clinical introduction A 60-year-old man had a long history of chronic hepatitis C. He presented to the emergency department with 2 days of progressive dyspnoea. Clinical manifestations included respiratory distress, cyanosis, digital clubbing, spider naevi on the upper chest and shifting dullness in the abdomen (see online supplementary figure S1). The ECG showed sinus tachycardia and left axis deviation. The chest radiography depicted blunting of right costophrenic angle with small pleural effusions and bilateral prominent pulmonary vascular markings (see online supplementary figure S2). The dyspnoea was exacerbated by upright posture and improved with recumbency. The hypoxaemia could not be corrected with administration of 100% oxygen. Contrast-enhanced transthoracic echocardiography was performed with injection of agitated saline (see figure 1 and online supplementary video). CT scan of the chest revealed some vascular abnormalities (see online supplementary figure S3–S6).
Question Which of the following is the next best step in management?
Catheter-based closure of intracardiac shunt
Pulmonary angiography and embolisation
Transjugular intrahepatic portosystemic shunt
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Contributors J-FC wrote most of the main text. C-HH contributed to comments for the image study. J-KL contributed to the echocardiogram.
Funding This study was supported by the Ministry of Science and Technology (MOST), 104-2220-E-151-001-.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.