Review Question - QID 104880

This patient presents with shock liver after global hypoperfusion from an acute myocardial infarction.

Shock liver is caused by ischemic hepatic injury secondary to hypotension. An acute, large elevations in AST & ALT can be detected, often greater than 1000. The patient should receive supportive care and if he survives the event, enzymes should be expected to return to normal limits within a few weeks.

Strassburg reviews the gastrointestinal disorders of the critically ill. Different grades of shock liver affect about 50% of all intensive-care patients, varying from a mild elevation of serum AST/ALT and bilirubin levels in septic patients to an acute onset of high serum aminotransferases after hemodynamic shock. Abnormalities can subside within days or progressively deteriorate when persistent hepatic microcirculatory failure is present.

Horvatits et al. discuss hypoxic liver injury and cholestasis in critically ill patients. Liver dysfunction at the intensive care unit can be divided into two main patterns: cholestatic and ischemic (shock liver). Both hepatic dysfunctions occur frequently and early in critical illness.

Illustration A depicts the blood flow of the liver. The liver receives dual blood supply, obtaining its oxygen both from the portal vein and the hepatic artery.

Incorrect Answers:
Answer 1: In alcoholic hepatitis, one would expect AST>ALT and one would not expect liver enzymes of this magnitude.
Answer 2: Tylenol intoxication could lead to a massive transaminitis but this patient has no history of medication overdose.
Answer 3: Ascending cholangitis would be expected if this patient had elevated bilirubin and fever and would not cause ALT and AST to be elevated to this level.
Answer 4: Primary biliary cirrhosis is an autoimmune disease of the biliary tract commonly found in middle aged women. Patients do not frequently develop a transaminitis of this magnitude.