Penetrating cardiac injuries carry a grave prognosis. We present a rare case of thoracic gunshot injury where the bullet ricocheted and lodged in the pericardium without causing damage to the adjacent cardiac structures. Multimodality imaging helped in localizing the bullet, assessing damage, and planning safe surgical removal without cardiopulmonary bypass. ( Level of Difficulty: Beginner. )

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INTRODUCTION: Pulmonary abnormalities and symptoms are common in patients with chronic liver disease. Hepatopulmonary syndrome is an important cause in a patient with hypoxemia and chronic liver disease. Hepatopulmonary syndrome consists of a triad of hepatic dysfunction and/or portal hypertension, intrapulmonary vascular dilatations and hypoxemia/ widened alveolararterial gradient. The present study evaluated the arterial blood gas levels and correlated these with 2D contrast echocardiographic findings in patients of liver cirrhosis. METHODS: 40 patients of liver cirrhosis were included in the study. All patients underwent ultrasonography, LFTs, biochemical tests and upper gastrointestinal endoscopy, chest X-ray, 2-D contrast enhanced transthoracic echocardiogram, viral markers and arterial blood gas analysis. The patients in whom arterial hypoxemia/ widened alveolar-arterial gradient was detected with a positive contrast echocardiogram were considered to have hepatopulmonary syndrome. Patients with intrinsic heart disease like patent foramen ovale, atrial septal defect, ventricular septal defect, haemoglobin less than 7gm% and history of COPD were excluded from the study. RESULTS: 4 patients of liver cirrhosis with hypoxemia had intrapulmonary vascular dilatations were labelled as hepatopulmonary syndrome. 2 additional patients with IPVDs had widened alveolar arterial gradient without hypoxemia and were also labelled as HPS. Dyspnoea (p=0.001), platypnea (p<0.001), clubbing (p=0.002) and cyanosis (p=0.001) were significantly commoner in the six patients of hepatopulmonary syndrome. Patients with cyanosis had poor prognosis. CONCLUSION: Hepatopulmonary syndrome is an important cause of hypoxemia in patients of liver cirrhosis. It is not uncommon in patients of liver cirrhosis. Platypnea is both sensitive as well as specific marker of the disease. Transthoracic contrast enhanced echocardiogram is a safe and accurate bedside tool for the detection of IPVDs.

RA is present in about 1% of the population and PBC is even rarer, with an estimated prevalence of 20/100,000 for woman and 2/100,000 for men and the association of both diseases by chance is very unusual. We report a rare association between primary biliary cirrhosis and rheumatoid arthritis.