Updated: 8/17/2020

Ischemic Hepatitis

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Snapshot
  • A 73-year-old man with chronic obstructive pulmonary disease, coronary artery disease, and hypertension is admitted to the intensive care unity for septic shock due to a left lower lobe pneumonia and treated with fluid resuscitation, pressors, and antibiotics. Liver function tests demonstrated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) over 1,000 U/L. Toxicology and viral hepatitis screening tests are negative.
Introduction
  • Clinical definition
    • acute hepatic injury secondary to hypoperfusion
  • Epidemiology
    • risk factors
      • ischemia and shock
      • respiratory failure
      • heart failure
  • Pathogenesis 
    • hypoperfusion to the liver leading to acute hepatocellular injury
    • most commonly from global hypoperfusion
    • less commonly from hepatic artery thrombosis due to dual blood supply
      • may occur with coexisting portal vein thrombosis
Presentation
  • Symptoms
    • weakness
    • fatigue
    • mental confusion (from cerebral hypoperfusion, not hepatic encephalopathy)
  • Physical exam
    • hypotension
    • tachycardia
Studies
  • Diagnostic testing
    • diagnostic approach
      • test for hepatocellular injury
      • evaluate for concomitant end-organ hypoperfusion
      • rule out viral and toxin etiologies
    • laboratory studies
      • liver function tests
        • rapid increase in AST and ALT to 25-250x normal limit
          • peak at 1-3 days after hypoperfusion event and normalize within 1-2 weeks
          • moderate increase in bilirubin and alkaline phosphatase
      • coagulation studies
        • normal PT and PTT
      • chemistries
        • normal albumin
        • rapid increase in creatinine is supportive of global hypoperfusion 
Differential
  • Acetaminophen toxicity
    • distinguishing factor
      • elevated serum paracetamol
  • Acute viral hepatitis
    • distinguishing factor
      • positive hepatitis viral screening
Treatment
  • Management approach
    • hemodynamic support and resuscitation
    • treat underlying etiology
Complications
  • Liver failure

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