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Congestive hepatopathy

Lawrence S Friedman, MD
Section Editor
Sanjiv Chopra, MD, MACP
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


The liver's complex vascular supply and high metabolic activity make it particularly vulnerable to circulatory disturbances. The severity and characteristics of hepatic injury depend upon the blood vessels that are involved and the degree to which injury is related to passive congestion or diminished perfusion [1].

There are several well-recognized forms of vascular injury to the liver, including Budd-Chiari syndrome, hepatic sinusoidal obstruction syndrome, passive congestion due to heart failure, hepatic infarction, and ischemic hepatitis. Congestive hepatopathy refers to hepatic manifestations attributable to passive hepatic congestion, as occurs in patients with right sided heart failure. Passive congestion often coexists with reduced cardiac output, making their relative contributions to hepatic injury intertwined. (See "Pathogenesis of liver injury in circulatory failure".)

This topic review will focus on passive congestion with a brief discussion on constrictive pericarditis, while discussions on Budd-Chiari syndrome, hepatic sinusoidal obstruction syndrome, ischemic hepatitis, and hepatic infarction are presented separately. (See "Budd-Chiari syndrome: Epidemiology, clinical manifestations, and diagnosis" and "Diagnosis of hepatic sinusoidal obstruction syndrome (veno-occlusive disease) following hematopoietic cell transplantation" and "Ischemic hepatitis, hepatic infarction, and ischemic cholangiopathy".)


Any cause of right-sided heart failure can result in hepatic congestion, including constrictive pericarditis, mitral stenosis, tricuspid regurgitation, cor pulmonale, and cardiomyopathy. Tricuspid regurgitation in particular can be associated with severe hepatic congestion because of the transmission of right ventricular pressure directly into the hepatic veins. Liver dysfunction and passive congestion are common in patients with congenital heart disease and single-ventricle physiology who have undergone the Fontan procedure, which directs systemic venous return to the pulmonary artery with bypass of the right ventricle [2].

Patients with hepatic congestion are usually asymptomatic. In such patients, hepatic congestion may be suggested only by abnormal liver biochemical tests during routine evaluation.


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Literature review current through: Sep 2016. | This topic last updated: Jun 4, 2015.
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  1. Giallourakis CC, Rosenberg PM, Friedman LS. The liver in heart failure. Clin Liver Dis 2002; 6:947.
  2. Asrani SK, Asrani NS, Freese DK, et al. Congenital heart disease and the liver. Hepatology 2012; 56:1160.
  3. Moussavian SN, Dincsoy HP, Goodman S, et al. Severe hyperbilirubinemia and coma in chronic congestive heart failure. Dig Dis Sci 1982; 27:175.
  4. Cohen JA, Kaplan MM. Left-sided heart failure presenting as hepatitis. Gastroenterology 1978; 74:583.
  5. LOGAN RG, MOWRY FM, JUDGE RD. Cardiac failure simulating viral hepatitis. Three cases with serum transaminase levels above 1,000. Ann Intern Med 1962; 56:784.
  6. Nouel O, Henrion J, Bernuau J, et al. Fulminant hepatic failure due to transient circulatory failure in patients with chronic heart disease. Dig Dis Sci 1980; 25:49.
  7. CASE RECORDS of the Massachusetts General Hospital; case 44212. N Engl J Med 1958; 258:1058.
  8. Kisloff B, Schaffer G. Fulminant hepatic failure secondary to congestive heart failure. Am J Dig Dis 1976; 21:895.
  9. Samsky MD, Patel CB, DeWald TA, et al. Cardiohepatic interactions in heart failure: an overview and clinical implications. J Am Coll Cardiol 2013; 61:2397.
  10. Dunn GD, Hayes P, Breen KJ, Schenker S. The liver in congestive heart failure: a review. Am J Med Sci 1973; 265:174.
  11. Allen LA, Felker GM, Pocock S, et al. Liver function abnormalities and outcome in patients with chronic heart failure: data from the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program. Eur J Heart Fail 2009; 11:170.
  12. SHERLOCK S. The liver in heart failure; relation of anatomical, functional, and circulatory changes. Br Heart J 1951; 13:273.
  13. Bynum TE, Boitnott JK, Maddrey WC. Ischemic hepatitis. Dig Dis Sci 1979; 24:129.
  14. Denis C, De Kerguennec C, Bernuau J, et al. Acute hypoxic hepatitis ('liver shock'): still a frequently overlooked cardiological diagnosis. Eur J Heart Fail 2004; 6:561.
  15. RICHMAN SM, DELMAN AJ, GROB D. Alterations in indices of liver function in congestive heart failure with particular reference to serum enzymes. Am J Med 1961; 30:211.
  16. Jafri SM. Hypercoagulability in heart failure. Semin Thromb Hemost 1997; 23:543.
  17. BESSMAN AN, EVANS JM. The blood ammonia in congestive heart failure. Am Heart J 1955; 50:715.
  18. Dogan Y, Soylu A, Kilickesmez O, et al. The value of hepatic diffusion-weighted MR imaging in demonstrating hepatic congestion secondary to pulmonary hypertension. Cardiovasc Ultrasound 2010; 8:28.
  19. Runyon BA. Cardiac ascites: a characterization. J Clin Gastroenterol 1988; 10:410.
  20. Sheer TA, Joo E, Runyon BA. Usefulness of serum N-terminal-ProBNP in distinguishing ascites due to cirrhosis from ascites due to heart failure. J Clin Gastroenterol 2010; 44:e23.
  21. Farias AQ, Silvestre OM, Garcia-Tsao G, et al. Serum B-type natriuretic peptide in the initial workup of patients with new onset ascites: a diagnostic accuracy study. Hepatology 2014; 59:1043.
  22. Dai DF, Swanson PE, Krieger EV, et al. Congestive hepatic fibrosis score: a novel histologic assessment of clinical severity. Mod Pathol 2014; 27:1552.
  23. Naschitz JE, Slobodin G, Lewis RJ, et al. Heart diseases affecting the liver and liver diseases affecting the heart. Am Heart J 2000; 140:111.
  24. Solano FX Jr, Young E, Talamo TS, Dekker A. Constrictive pericarditis mimicking Budd-Chiari syndrome. Am J Med 1986; 80:113.
  25. Arora A, Tandon N, Sharma MP, Acharya SK. Constrictive pericarditis masquerading as Budd-Chiari syndrome. J Clin Gastroenterol 1991; 13:178.