Ischemic hepatitis, hepatic infarction, and ischemic cholangiopathy
- Lawrence S Friedman, MD
Lawrence S Friedman, MD
- Section Editor — General Gastroenterology
- Professor of Medicine
- Harvard Medical School
- Tufts University School of Medicine
- Section Editor
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology
- Section Editor — Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
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 .
There are several well-recognized forms of vascular injury to the liver, including Budd-Chiari syndrome, hepatic sinusoidal obstruction syndrome (veno-occlusive disease), passive congestion due to heart failure, hepatic infarction, and ischemic hepatitis. (See "Pathogenesis of liver injury in circulatory failure".)
This topic review will focus on ischemic hepatitis, hepatic infarction, and ischemic cholangiopathy, while discussions on Budd-Chiari syndrome, hepatic sinusoidal obstruction syndrome, and congestive hepatopathy 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 "Congestive hepatopathy".)
ISCHEMIC HEPATITIS (SHOCK LIVER, HYPOXIC HEPATITIS)
Ischemic hepatitis (also referred to as shock liver, hypoxic hepatitis, and occasionally [and erroneously] acute hepatic infarction) refers to diffuse hepatic injury resulting from acute hypoperfusion . Ischemic hepatitis accounts for 1 to 2.5 percent of patients admitted to an intensive care unit [3,4].
The term hepatitis is somewhat of a misnomer since the injury is not mediated by an inflammatory process. Nevertheless, the profound elevation in aminotransferases is similar to that seen in toxic hepatitis (such as caused by acetaminophen) and acute viral hepatitis, two disorders that should be considered prominently as part of the differential diagnosis (see "Approach to the patient with abnormal liver biochemical and function tests"). The term ischemic hepatitis is preferable to "shock liver" since the syndrome can occur in the absence of shock. The diffuse nature of the injury distinguishes it from hepatic infarction, which represents focal injury.
- Giallourakis CC, Rosenberg PM, Friedman LS. The liver in heart failure. Clin Liver Dis 2002; 6:947.
- Bynum TE, Boitnott JK, Maddrey WC. Ischemic hepatitis. Dig Dis Sci 1979; 24:129.
- Birrer R, Takuda Y, Takara T. Hypoxic hepatopathy: pathophysiology and prognosis. Intern Med 2007; 46:1063.
- Tapper EB, Sengupta N, Bonder A. The Incidence and Outcomes of Ischemic Hepatitis: A Systematic Review with Meta-Analysis. Am J Med 2015.
- Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: clinical presentation and pathogenesis. Am J Med 2000; 109:109.
- Henrion J, Minette P, Colin L, et al. Hypoxic hepatitis caused by acute exacerbation of chronic respiratory failure: a case-controlled, hemodynamic study of 17 consecutive cases. Hepatology 1999; 29:427.
- Gibson PR, Dudley FJ. Ischemic hepatitis: clinical features, diagnosis and prognosis. Aust N Z J Med 1984; 14:822.
- Henrion J, Schapira M, Luwaert R, et al. Hypoxic hepatitis: clinical and hemodynamic study in 142 consecutive cases. Medicine (Baltimore) 2003; 82:392.
- Henrion J, Deltenre P, De Maeght S, et al. Acute lower limb ischemia as a triggering condition in hypoxic hepatitis: a study of five cases. J Clin Gastroenterol 2011; 45:274.
- Cohen JA, Kaplan MM. Left-sided heart failure presenting as hepatitis. Gastroenterology 1978; 74:583.
- 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.
- Gitlin N, Serio KM. Ischemic hepatitis: widening horizons. Am J Gastroenterol 1992; 87:831.
- Fuhrmann V, Madl C, Mueller C, et al. Hepatopulmonary syndrome in patients with hypoxic hepatitis. Gastroenterology 2006; 131:69.
- Cassidy WM, Reynolds TB. Serum lactic dehydrogenase in the differential diagnosis of acute hepatocellular injury. J Clin Gastroenterol 1994; 19:118.
- Angehrn W, Schmid E, Althaus F, et al. Effect of dopamine on hepatosplanchnic blood flow. J Cardiovasc Pharmacol 1980; 2:257.
- Desai A, Kadleck D, Hufford L, Leikin JB. N-acetylcysteine use in ischemic hepatitis. Am J Ther 2006; 13:80.
- Drolz A, Horvatits T, Michl B, et al. Statin therapy is associated with reduced incidence of hypoxic hepatitis in critically ill patients. J Hepatol 2014; 60:1187.
- Raurich JM, Llompart-Pou JA, Ferreruela M, et al. Hypoxic hepatitis in critically ill patients: incidence, etiology and risk factors for mortality. J Anesth 2011; 25:50.
- Jäger B, Drolz A, Michl B, et al. Jaundice increases the rate of complications and one-year mortality in patients with hypoxic hepatitis. Hepatology 2012; 56:2297.
- Fuhrmann V, Kneidinger N, Herkner H, et al. Impact of hypoxic hepatitis on mortality in the intensive care unit. Intensive Care Med 2011; 37:1302.
- Henrion J, Colin L, Schmitz A, et al. Ischemic hepatitis in cirrhosis. Rare but lethal. J Clin Gastroenterol 1993; 16:35.
- Pauwels A, Lévy VG. Ischemic hepatitis in cirrhosis: not so rare, not always lethal. J Clin Gastroenterol 1993; 17:88.
- Taylor RM, Tujios S, Jinjuvadia K, et al. Short and long-term outcomes in patients with acute liver failure due to ischemic hepatitis. Dig Dis Sci 2012; 57:777.
- Chen V, Hamilton J, Qizilbash A. Hepatic infarction. A clinicopathologic study of seven cases. Arch Pathol Lab Med 1976; 100:32.
- Tzakis AG, Gordon RD, Shaw BW Jr, et al. Clinical presentation of hepatic artery thrombosis after liver transplantation in the cyclosporine era. Transplantation 1985; 40:667.
- Ludwig J, Gores GJ. Images in clinical medicine. Infarct cavities in a hepatic allograft. N Engl J Med 1995; 333:1117.
- Henrich WL, Huehnegarth RJ, Rösch J, Melnyk CS. Gallbladder and liver infarction occurring as a complication of acute bacterial endocarditis. Gastroenterology 1975; 68:1602.
- Cohen SE, Safadi R, Verstandig A, et al. Liver-spleen infarcts following transcatheter chemoembolization: a case report and review of the literature on adverse effects. Dig Dis Sci 1997; 42:938.
- Chuang CH, Chen CY, Tsai HM. Hepatic infarction and hepatic artery pseudoaneurysm with peritoneal bleeding after radiofrequency ablation for hepatoma. Clin Gastroenterol Hepatol 2005; 3:A23.
- Kim YS, Rhim H, Lim HK, et al. Hepatic infarction after radiofrequency ablation of hepatocellular carcinoma with an internally cooled electrode. J Vasc Interv Radiol 2007; 18:1126.
- Jang HY, Cha SW, Lee BH, et al. Hepatic and splenic infarction and bowel ischemia following endoscopic ultrasound-guided celiac plexus neurolysis. Clin Endosc 2013; 46:306.
- Lopera JE, Katabathina V, Bosworth B, et al. Segmental liver ischemia/infarction after elective transjugular intrahepatic portosystemic shunt creation: clinical outcomes in 10 patients. J Vasc Interv Radiol 2015; 26:835.
- Zissin R, Yaffe D, Fejgin M, et al. Hepatic infarction in preeclampsia as part of the HELLP syndrome: CT appearance. Abdom Imaging 1999; 24:594.
- Gauthier N, Cornud F, Vissuzaine C. Liver infarction in sickle cell disease. AJR Am J Roentgenol 1985; 144:1089.
- Adler DD, Glazer GM, Silver TM. Computed tomography of liver infarction. AJR Am J Roentgenol 1984; 142:315.
- Holbert BL, Baron RL, Dodd GD 3rd. Hepatic infarction caused by arterial insufficiency: spectrum and evolution of CT findings. AJR Am J Roentgenol 1996; 166:815.
- Fields MS, Desai RK. Hepatic infarction: MRI appearance. Cleve Clin J Med 1991; 58:353.
- Deltenre P, Valla DC. Ischemic cholangiopathy. J Hepatol 2006; 44:806.
- Cameron AM, Busuttil RW. Ischemic cholangiopathy after liver transplantation. Hepatobiliary Pancreat Dis Int 2005; 4:495.
- Imam MH, Talwalkar JA, Lindor KD. Secondary sclerosing cholangitis: pathogenesis, diagnosis, and management. Clin Liver Dis 2013; 17:269.
- Terblanche J, Allison HF, Northover JM. An ischemic basis for biliary strictures. Surgery 1983; 94:52.
- Ludwig J, Kim CH, Wiesner RH, Krom RA. Floxuridine-induced sclerosing cholangitis: an ischemic cholangiopathy? Hepatology 1989; 9:215.
- Cherqui D, Palazzo L, Piedbois P, et al. Common bile duct stricture as a late complication of upper abdominal radiotherapy. J Hepatol 1994; 20:693.
- Le Thi Huong D, Valla D, Franco D, et al. Cholangitis associated with paroxysmal nocturnal hemoglobinuria: another instance of ischemic cholangiopathy? Gastroenterology 1995; 109:1338.
- Vlachou PA, Colak E, Koculym A, et al. Improvement of ischemic cholangiopathy in three patients with hereditary hemorrhagic telangiectasia following treatment with bevacizumab. J Hepatol 2013; 59:186.
- Gelbmann CM, Rümmele P, Wimmer M, et al. Ischemic-like cholangiopathy with secondary sclerosing cholangitis in critically ill patients. Am J Gastroenterol 2007; 102:1221.
- Horvatits T, Trauner M, Fuhrmann V. Hypoxic liver injury and cholestasis in critically ill patients. Curr Opin Crit Care 2013; 19:128.
- Cohen L, Angot E, Goria O, et al. [Ischemic cholangiopathy induced by extended burns]. Ann Pathol 2013; 33:113.
- Ludwig J, Batts KP, MacCarty RL. Ischemic cholangitis in hepatic allografts. Mayo Clin Proc 1992; 67:519.
- Sanchez-Urdazpal L, Gores GJ, Ward EM, et al. Diagnostic features and clinical outcome of ischemic-type biliary complications after liver transplantation. Hepatology 1993; 17:605.
- ISCHEMIC HEPATITIS (SHOCK LIVER, HYPOXIC HEPATITIS)
- Clinical manifestations
- HEPATIC INFARCTION
- Clinical manifestations
- ISCHEMIC CHOLANGIOPATHY
- Clinical manifestations
- SUMMARY AND RECOMMENDATIONS
- Ischemic hepatitis
- Hepatic infarction
- Ischemic cholangiopathy