A 66-year-old man with Child-B alcoholic cirrhosis presented with melaena due to hemorrhagic gastritis. Clinical examination revealed cyanosis and clubbing accompanied by severe hypoxaemia without signs of obstructive or restrictive lung disease. Contrast-enhanced echocardiography showed right to left shunt due to intrapulmonary shunting leading to the diagnosis of hepatopulmonary syndrome. Hypoxaemia in patients suffering from chronic liver disease can have different causes but in the presence of cyanosis and clubbing without signs of lung disease the hepatopulmonary syndrome should be suspected. When presence of intrapulmonary shunts has been proven by contrast-enhanced echocardiography, a 100% oxygen test can determine the need for pulmonary angiography and thus determine the indication for interventional therapy or liver transplantation. The patient described was treated supportively with long-term oxygen therapy 6 l/min. Three months later his clinical condition was stable. An attempt to reduce the need for nasal oxygen failed.
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