Correct!
5. All of the above

Liver transplantation is the only well-recognized treatment for HPS. The degree of arterial hypoxemia appears to influence survival after liver transplantation. Swanson and colleagues (4) at the Mayo Clinic demonstrated in a case-control study involving 61 HPS patients that long-term survival for HPS patients is worse in the subgroup with lower baseline PaO2 (50 mmHg). Since not all patients are appropriate for immediate liver transplantation, interest has surfaced for other therapies. Both methylene blue and garlic have been proposed (5,6).

Our patient was begun on garlic 500 mg twice a day while being evaluated for liver transplantation. Her PaO2 improved marginally to 47 mm Hg.

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References

1. Montgomery H, Zinsser HF, Howwitz O. Oxygen tension of tissues by the polarographic method. II Detection of right to left shunts by changes in skin oxygen tension resulting from inhalation of oxygen. Circulation. 1950;2(6):845-9. [PubMed]
2. Kennedy TC, Knudson RJ. Exercise-aggravated hypoxemia and orthodeoxia in cirrhosis. Chest. 1977;72(3):305-9. [PubMed]
3. Grace JA, Angus PW. Hepatopulmonary syndrome: update on recent advances in pathophysiology, investigation, and treatment. J Gastroenterol Hepatol. 2013;28(2):213-9. [CrossRef] [PubMed]
4. Swanson KL, Wiesner RH, Krowka MJ. Natural history of hepatopulmonary syndrome: Impact of liver transplantation. Hepatology. 2005;41(5):1122-9. [CrossRef] [PubMed]
5. Schenk P, Madl C, Rezaie-Majd S, Lehr S, Müller C. Methylene blue improves the hepatopulmonary syndrome. Ann Intern Med. 2000;133(9):701-6. [CrossRef] [PubMed]
6. De BK, Dutta D, Pal SK, Gangopadhyay S, Das Baksi S, Pani A. The role of garlic in hepatopulmonary syndrome: a randomized controlled trial. Can J Gastroenterol. 2010;24(3):183-8. [PubMed]

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