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Updated: Dec 13 2021

Ischemic Hepatitis

  • 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
          • 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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