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 etiology 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 login to view 3 more bullets coagulation studies login to view 1 more bullet chemistries login to view 2 more bullets 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