Polo Kostecki, DO1, Renieh M. Nabaty, MD2, Omar Shamaa, MD2, Muhammad Zarrar Khan, MD3, Medha R. Cherabuddi, MD4, Kimberly A.. Brown, MD5, Reena Salgia, MD2 1Henry Ford Health, Warren, MI; 2Henry Ford Health, Detroit, MI; 3Henry Ford Hospital, Detroit, MI; 4Henry Ford Health, West Bloomfield, MI; 54. Division of Gastroenterology and Hepatology, Henry Ford Health,, Detroit, MI Introduction: Hepatopulmonary syndrome (HPS) is a pulmonary vascular complication of cirrhosis characterized by intrapulmonary vasodilation and impaired oxygenation. Liver transplantation (LT) is the only curative treatment, but persistent hypoxemia occurs in up to 25% of HPS patients post-LT [1]. We present a patient with refractory post-LT HPS who improved with high-dose garlic therapy.
Case Description/
Methods: A 67-year-old man with decompensated alcohol-related cirrhosis with portal hypertension and pre-transplant oxygen requirements of 3–6 L/min for >1 year prior to presentation developed worsening hypoxemia following orthotopic LT. Despite appropriate post-LT graft function, he experienced positional desaturation (70–80% upright, 80–90% supine) on 6 L/min of oxygen. A comprehensive workup, including contrast-enhanced echocardiography, CT chest with IV contrast, and pulmonary angiography, excluded thromboembolic and structural pulmonary pathology. Findings were consistent with persistent HPS.
Initial trials of high-flow nasal cannula and intravenous methylene blue (100 mg) had no effect. After multidisciplinary discussion, the patient was started on high-dose garlic (4 g daily), based on limited data supporting its nitric oxide–modulating effects. Within one week, oxygenation improved and discharged on 10–15 L/min. By three months, oxygen was discontinued. Discussion: Persistent post-LT HPS is challenging, with limited options. Extracorporeal membrane oxygenation (ECMO) was not pursued due to uncertain timing, and pulmonary vasodilators were withheld to avoid exacerbating shunting and worsening hypoxemia. Garlic was used based on limited data and expert input as a low-risk option [2,3]. Although the exact mechanism is not understood, garlic may cause uniform vasodilation and redistribute blood flow from dilated basal to better-ventilated upper lung zones, improving ventilation/perfusion and reducing nitric oxide [3]. As HPS recovery is often gradual, garlic may safely bridge this period. Given its safety, garlic may be a supportive option in select patients. Further studies are needed to define its role in post-LT hypoxemia.
1. Pascasio JM, et al. Am J Transplant. 2014;14(6):1391–1399. 2. Abrams GA, Fallon MB. J Clin Gastroenterol. 1998;27(3):232–235. 3. De BK, et al. Can J Gastroenterol. 2010;24(3):183–188.
Disclosures: Polo Kostecki indicated no relevant financial relationships. Renieh Nabaty indicated no relevant financial relationships. Omar Shamaa indicated no relevant financial relationships. Muhammad Zarrar Khan indicated no relevant financial relationships. Medha Cherabuddi indicated no relevant financial relationships. Kimberly Brown: Intercept, Gilead, Salix, Ipsen, Madrigal – Advisor or Review Panel Member, Advisory Committee/Board Member, Speakers Bureau. Mallinckrodt – Advisory Committee/Board Member. Mallinckrodt – Advisory Committee/Board Member, Speakers Bureau. Mallinckrodt – Speakers Bureau. Reena Salgia indicated no relevant financial relationships.
Polo Kostecki, DO1, Renieh M. Nabaty, MD2, Omar Shamaa, MD2, Muhammad Zarrar Khan, MD3, Medha R. Cherabuddi, MD4, Kimberly A.. Brown, MD5, Reena Salgia, MD2. P3824 - Breathing Easier: High Dose Garlic for Refractory HPS After Liver Transplant, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
