Ischaemic hepatitis🎥

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Ischaemic Hepatitis

Ischaemic hepatitis, also known as shock liver, is a form of acute liver injury resulting from a transient reduction in hepatic blood flow. It typically occurs in the context of hypotension, shock, or decompensated heart failure, leading to hepatocellular hypoxia and necrosis.


Peak Incidence

  • Most commonly affects individuals between 50 and 80 years of age.

Pathophysiology

  • A sudden drop in hepatic perfusion leads to hypoxic injury of hepatocytes.
  • The central zones (zone 3) of the hepatic lobules are most vulnerable due to their relatively poor oxygen supply.
  • Common triggers include cardiogenic shock, septic shock, massive blood loss, or acute decompensated heart failure.

Symptoms

  • Many cases are asymptomatic and discovered incidentally on blood tests.
  • If symptomatic, patients may report:
    • Fatigue.
    • Nausea and vomiting.
    • Mild right upper quadrant (RUQ) discomfort.
    • Jaundice (uncommon unless liver injury is severe).

Signs

  • Features of hypotension or shock:
    • Cold peripheries.
    • Tachycardia.
    • Altered mental status.
  • Signs of heart failure (if relevant):
    • Raised jugular venous pressure (JVP).
    • Peripheral oedema.
    • Hepatomegaly.
  • Mild RUQ tenderness may be present.

Diagnosis

Blood Tests

  • AST and ALT: Markedly elevated, typically >1000 IU/L. Levels often fall rapidly within a few days if the insult resolves.
  • Bilirubin: May be elevated.
  • Alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT): Normal or mildly raised.
  • Prothrombin time (PT)/International Normalised Ratio (INR): May be prolonged, reflecting impaired synthetic function.
  • Lactate: May be elevated if associated with shock or hypoperfusion.

Imaging

  • Abdominal ultrasound or CT scan: Often normal but may show hepatic congestion in the context of heart failure.
  • Echocardiography: Indicated if cardiac dysfunction is suspected as the precipitating cause.

Complications

  • Acute liver failure (rare).
  • Multi-organ failure (MOF).
  • Coagulopathy due to impaired hepatic synthesis of clotting factors.
  • Hepatic encephalopathy in severe cases.
  • Acute kidney injury due to hypoperfusion.

Management

  • Supportive care is the mainstay of treatment, as the liver injury is usually reversible.
    • Close monitoring of liver function and coagulation profile.
  • Treat the underlying cause:
    • Optimise fluid status and blood pressure (e.g., IV fluids, vasopressors).
    • Manage sepsis if present.
    • Address underlying cardiac dysfunction or arrhythmia.
  • Intensive care support may be required in severe cases.

FAQ from our users

What are the causes of ischaemic hepatitis?
  • Severe hypotension
  • Heart failure
  • Sepsis
  • Massive blood loss
  • Respiratory failure
  • Burns
  • Thromboembolism
How long does ischaemic hepatitis last?

Liver enzymes typically peak within 24-72 hours and return to normal within 1-2 weeks if perfusion is restored.

Common pitfalls in a clinical setting

Common pitfalls in a clinical setting
  • Do not forget to rule out other causes of acute liver injury when assessing someone with suspected ischaemic hepatitis, such as paracetamol overdose, viral hepatitis, or drug-induced liver injury.
  • Do not delay treatment of shock or sepsis can worsen liver injury and lead to multi-organ failure.