Ischemic hepatitis: Clinical presentation and pathogenesis

BACKGROUND: The pathophysiology of ischemic hepatitis, otherwise known as " shock liver," is poorly understood, although it is believed to be the resul t of a reduction in systemic blood flow as typically occurs in shock. The a im of this study was to investigate the importance of this phenomenon as we ll as other clinical features in patients with ischemic hepatitis. METHODS: We identified a cohort of 31 patients (case group) who met the mos t commonly accepted definition of ischemic hepatitis (an acute reversible e levation in either the serum alanine or aspartate aminotransferase level of at least 20 times the upper limit of normal, excluding known causes of acu te hepatitis or hepatocellular injury, in an appropriate clinical setting). We also evaluated the clinical features and serum aminotransferase levels in a cohort (the control group) of 31 previously healthy patients who susta ined major nonhepatic trauma at San Francisco General Hospital, a major tra uma center. Both groups of patients had documented systolic blood pressures <75 mm Hg for at least 15 minutes. Clinical and hemodynamic (invasive and noninvasive) data were recorded. RESULTS: Despite the marked reduction in blood pressure, no patient in the control group developed ischemic hepatitis. The mean (+/- SD) peak serum as partate aminotransferase level in the control group was only 78 +/- 72 IU,i n contrast with a mean peak of 2,088 +/- 2,165 IU in the case group. All 31 patients with ischemic hepatitis had evidence of underlying organic heart disease, 29 (94%) of whom had right-sided heart failure. CONCLUSIONS: Systemic hypotension or shock alone did not lead to ischemic h epatitis in any patient. The vast majority of patients with ischemic hepati tis had severe underlying cardiac disease that had often led to passive con gestion of the liver. These data lead us to propose that right-sided heart failure, with resultant hepatic venous congestion, may predispose the liver to hepatic injury induced by a hypotensive event. Am I Med. 2000;109:109-1 13. (C) 2000 by Excerpta Medica, Inc.