INTRODUCTION 
The liver is a unique organ that is connected in series between 
the portal system and lungs. In patients with liver diseases 
and / portal hypertension, constituents of venous blood arising 
from both liver and the portal system can directly injure the 
pulmonary vasculature and endothelium. Pulmonary 
vascular complications in liver disease or portal hypertension 
have long been documented in the form of porto-pulmonary 
hypertension (POPH) and hepato-pulmonary syndrome (HPS) 
producing important morbidity and mortality, including the 
setting of liver transplantation. There has been increasing 
recognition of the importance of these pulmonary vascular 
complications of liver disease, with increasing realization that 
these complications inuence survival before, during and 
after transplantation.

Porto-pulmonary hypertension (POPH) is best dened as 
pulmonary arterial hypertension (PAH) associated with portal 
hypertension, whether or not the portal hypertension is due to 
underlying liver disease. Hepato-pulmonary syndrome (HPS) 
is characterized by triad of arterial deoxygenation, intra-
pulmonary vascular dilatation and liver disease. HPS can 
occur with any degree of liver disease, ranging from well 
compensated chronic liver disease without cirrhosis to non-
cirrhotic portal hypertension and cirrhosis.

In previous studies cardiac catheterization was used to 

diagnose PAH in patients of CLD. Recently echocardiography, 
a non invasive technique, is used to diagnose PAH. 
Echocardiography is a simple non invasive technique which 
replaced invasive catheterization to rule out hepato 
pulmonary syndrome.

The primary objective of our study was to check for the 
prevalence of pulmonary hypertension in the patients of 
chronic liver disease by trans-thoracic echocardiography, 
presenting to the medicine in patient department, with or 
without symptoms suggestive of cardio-vascular involvement. 
We also analyzed causative factors prevailing in the region 
(Bundelkhand) for causing CLD.

OBJECTIVES 
Ÿ The primary objective of our study was to check for the 

prevalence of pulmonary hypertension in the patients of 
chronic liver disease by trans-thoracic echocardiography, 
presenting with or without symptoms suggestive of 
cardiovascular involvement. 

Ÿ To plan for further study to see effects of available drugs 
for pulmonary hypertension with chronic liver disease and 
the use of the presence of pulmonary hypertension as one 
of the criteria for referral to liver transplant.

MATERIAL AND METHODS 
This cross sectional study was conducted on patients 

TO STUDY THE INCIDENCE OF PULMONARY HYPERTENSION IN 
PATIENTS OF CHRONIC LIVER DISEASE

Original Research Paper

Dr. Rajat Jain
Associate Professor Department of Medicine, M.L.B. Medical College, 
Jhansi 

  X 87GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

General Medicine

Background : Cirrhosis and portal hypertension have been found to be associated with pulmonary 
hypertension and pulmonary dysfunction. Several clinical studies have demonstrated 20% higher 

prevalence of pulmonary hypertension in patients with advanced liver disease and portal hypertension. There has been 
increasing recognition of the importance of these pulmonary vascular complications of liver disease, with increasing 
realization that these complications inuence survival before, during and after liver transplantation.
Aim of the Study: The primary objective of our study was to check for the prevalence of pulmonary hypertension in the patients 
of chronic liver disease by transthoracic echocardiography, presenting  with or without symptoms suggestive of  cardio-
vascular involvement. 
The secondary objective of this study was to plan for further study to see the effects of available drugs for pulmonary 
hypertension on patients with pulmonary hypertension with chronic liver disease and the use of presence of pulmonary 
hypertension as one of the criteria for referral to liver transplantation.
Material and Methods: This study was conducted in medicine department of MLB medical college, Jhansi from May 2018 to 
May 2019. 90 patients of chronic liver disease were taken as subjects and 75 age and sex matched patients without CLD were 
taken as controls.  Based upon their symptoms, the subjects were divided into 2 groups:Group A – patients of CLD presenting 
with symptoms suggestive of CV involvement and Group B – patients of CLD presenting without symptoms suggestive of CV 
involvement
Observation: In our study, there were 72 male patients (42 in group A, 30 in group B) and 18 female patients (12 in group A and 6 
in group B). Majority of the patients were above 40 years of age (60 out of total 90 patients). The cause of CLD in majority of the 
subjects (50%) was chronic alcoholism, in 30% it was chronic hepatitis-B  while 20% had other causes. 40% of our subjects were 
found to have pulmonary hypertension, 44.44% of all the patients of group A and 33.33% of all patients of group B.
Conclusion: There is high incidence of pulmonary hypertension in patients of CLD and alcohol addiction is the most common 
cause of CLD in Bundelkhand region. Trans-thoracic echocardiography is a simple and non-invasive technique for diagnosis 
of pulmonary hypertension.

ABSTRACT

KEYWORDS : Portal hypertension, pulmonary hypertension, echocardiography.

Dr. Zaki Siddiqui*
Assistant Professor Department of Medicine, M.L.B. Medical College, Jhansi 
*Corresponding Author

Gauri Naryani Medical Student, M,L,B, Medical College, Jhansi.

VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Swati Azad Medical Student, M,L,B, Medical College, Jhansi.

Sanya Jain Medical Student, K.I.M.S., Karad.



88 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

admitted to the medicine wards of Maharani Laxmi Bai 
Medical College, Jhansi after obtaining ethical clearance 
from the institutional ethics committee. Informed consent was 
taken from the participants prior to the study. In our study, 54 
patients of chronic liver disease presenting with symptoms 
suggestive of cardiovascular involvement and 36 patients 
without these symptoms  were screened by clinical 
examination, blood investigations, USG abdomen, chest X-
Ray, ECG and trans-thoracic echocardiography [the following 
symptoms  breathlessness, pedal edema, cough, dizziness, 
palpitations, chest pain were considered to be suggestive of 
cardio-vascular involvement].  We also examined 75 age and 
sex matched controls [excluding CLD]. 

We excluded patients of interstitial lung disease (ILD), chronic 
obstructive airway disease (COAD), valvular heart disease, 
cardiomyopathy and pulmonary tuberculosis both from the 
study and control groups.

A total of 90 patients of CLD and 75 controls were examined 
using the echocardiography machine of our department ( 
HITACHI ALOKA Alpha 6) PNDT/ACT/94/2016, for RV 
dimensions, contractibility and evidence of pulmonary 
hypertension or RV systolic function by tricuspid valve annular 
motion technique.

Grading of Pulmonary Artery Hypertension by echo 
cardiography:

2SRVP =  4*TRV  + RAP
2PAP =  4*TRV

SRVP- systolic right ventricular pressure; TRV- tricuspid 
regurgitation velocity; RAP- right atrial pressure; PAP- 
pulmonary artery pressure]

Calculation of RAP

Other factors included right atrial volume index, inferior vena 
cava diameter, eccentricity index, presence of pulmonary 
embolism and TAPSE in grading.

Data collected was entered into Excel. Chi-square and 
Fischer's exact test were done for qualitative data. Bivariate 
analysis was done to identify selected risk factors for the 
outcome.

OBSERVATIONS 
Table 1: Demographic variables among patients of group A 
and group B

In our study, there were 72 male patients (42 in group A, 30 in 
group B) and 18 female patients (12 in group A and 6 in group 
B). Majority of the patients were above 40 years of age (60 out 

of total 90 patients). 

Chart 1: Graphical representation of male :female ratio 
among patients of group A and group B

Chart 2: Graphical representation of causative agents of 
CLD.

Chart 3: Graphical representation of age distribution in 
group A  Group B.

Table 2: Prevalence of Pulmonary Hypertension in patients 
of Group A and Group B

Chart 4: Graphical representation of severity of RV 
enlargement

Chart 5: Graphical representation of prevalence and 
severity of pulmonary artery hypertension (PAH)

VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Severity SPAP

Mild >35 mmHg

Moderate >50 mmHg

Severe >60 mmHg

IVC Diameter (cm) Response to sniff RA Pressure (mmHg)

≤2.1 >50% collapse 3

≥2.1 <50% collapse 8

>2.1 <50% collapse 15

Variables Group A
(N=54)

Group B
(N=36)

Controls
(N=75)

Sex
     Male
     Female

42
12

30
6

60
15

Age
    <40 years
    >40 years

18
36

12
24

25
50

Residence
    Urban
    Rural  

36
18

9
27

Present Absent

Group A 24 (44.44%) 30 (55.55%)

Group B 12 (33.33%) 24 (66.67%)

Controls 04 (5.33%) 71 (94.66%)



26.66% of our subjects (24 out of 90) were found to have mild 
PAH, 3.33% (3 out of 90) had moderate PAH, while none of the 
subjects in our study had severe PAH as assessed using trans 
thoracic echo cardiography.

In our study, all of the subjects of both the groups were found to 
have normal ndings of ECG, chest X-ray and right ventricular 
systolic function.

Chart 6: Graphical representation of USG abdomen 
ndings

Chart 7: Graphical ndings of USG ndings of liver

DISCUSSION
Chronic liver diseases (CLDs) are a set of diseases 
characterized by decreased hepatic function as a result of 
chronic inammation or insult to the liver. These can progress 
through stages of brosis to the end stage disease, cirrhosis. 
Cirrhosis is irreversible and is dened by brosis, damage 
and regeneration of hepatocytes, altered hepatic architecture 
and decreased hepatic function. The patients of CLDs may 
suffer from complications like hepato-renal syndrome, 
hepato-pulmonary syndrome and porto-pulmonary 
hypertension. 

Pulmonary hypertension is the resting mean pulmonary 
arterial pressure in excess of 25mmHg. Pulmonary 
involvement is common in patients with portal hypertension 
and can manifest in diverse manners. Changes in pulmonary 
arterial resistance, manifesting either as hepato-pulmonary 
syndrome or porto-pulmonary hypertension (PPHTN), have 
been increasingly recognized in these patients in recent 
years.  Porto-pulmonary hypertension is combination of portal 
hypertension and pre-capillary pulmonary hypertension. 
Several clinical studies and autopsy ndings have 
demonstrated a 20% higher prevalence of pulmonary 
hypertension in patients with advanced liver disease and 
portal hypertension, the histological ndings of which show 
features similar to those seen in pulmonary hypertension from 
other causes.  

In our study, we screened 90 patients of chronic liver disease 
for symptoms suggestive of cardio-vascular complications 
and presence of pulmonary hypertension by chest X-ray, ECG, 
echocardiography along with the routine blood investigations 
and USG abdomen. The ndings of chest X-ray and ECG were 
normal in all of the subjects. The ultrasonography of abdomen 

revealed that all of our patients had ascitis,  70% (66 out of 90) 
patients had splenomegaly, 13.33% (12 out of 90) patients had 
hepatomegaly,  3 .33% (3  out  of  90)  pat ients  had 
hepatosplenomegaly while the rest had small liver with course 
echo-texture.

44.44% of patients of group A (i.e. those with symptoms of CV 
involvement) were found to have pulmonary hypertension and 
33.33% of patients of group B (i.e. those without symptoms of 
CV involvement) indicating that even in the absence of 
symptoms pulmonary hypertension can be present in patients 
with chronic liver disease. It was also found that presence of 
pulmonary hypertension was not in relation with the severity 
and duration of CLD. 

CONCLUSION
1) The study concludes that there is high incidence of 

pulmonary hypertension in patients of CLD
2) Trans-thoracic Echocardiography is a simple and non-

invasive technique for  diagnosing pulmonary 
hypertension in patients of CLD

3) Alcohol addiction is the most common cause of CLD in 
Bundelkhand region (preventable cause)

4) Presence of pulmonary hypertension does not correlate 
with the severity of underlying liver disease (to be 
conrmed by further studies).

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VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra