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 result of a reduction in systemic blood flow as typically occurs in shock. The aim of this study was to investigate the importance of this phenomenon as well as other clinical features in patients with ischemic hepatitis.


METHODS
We identified a cohort of 31 patients (case group) who met the most commonly accepted definition of ischemic hepatitis (an acute reversible elevation in either the serum alanine or aspartate aminotransferase level of at least 20 times the upper limit of normal, excluding known causes of acute 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 sustained major nonhepatic trauma at San Francisco General Hospital, a major trauma 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 aspartate aminotransferase level in the control group was only 78 +/- 72 IU, in 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 hepatitis in any patient. The vast majority of patients with ischemic hepatitis had severe underlying cardiac disease that had often led to passive congestion 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.
Seeto
R K
RK
Department of Medicine (RKS, BF), Division of Gastroenterology, University of California, San Francisco, San Francisco, California, USA.
Fenn
B
B
Rockey
D C
DC
D000208:Acute Disease; D000328:Adult; D000410:Alanine Transaminase / Q000097:blood; D001219:Aspartate Aminotransferases / Q000097:blood; D001794:Blood Pressure / Q000502:physiology; D002303:Cardiac Output, Low / Q000150:complications; D015331:Cohort Studies; D004198:Disease Susceptibility; D005260:Female; D006331:Heart Diseases / Q000150:complications; D006505:Hepatitis / Q000201:enzymology / Q000209:etiology / Q000503:physiopathology*; D006801:Humans; D007022:Hypotension / Q000150:complications; D007511:Ischemia / Q000201:enzymology / Q000209:etiology / Q000503:physiopathology*; D008099:Liver / Q000098:blood supply* / Q000201:enzymology / Q000293:injuries; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012769:Shock / Q000150:complications / Q000503:physiopathology; D014689:Venous Insufficiency / Q000150:complications; D018497:Ventricular Dysfunction, Right / Q000150:complications
D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase