Congestive hepatopathy

Alan Cheng

Congestive Hepatopathy

Definition hepatic manifestations 2/2 passive hepatic congestion from R heart failure of any cause Can develop in a few days or over several years

Clinical Manifestations

Often mild and asymptomatic, detected incidentally via LFTs RUQ pain from capsule stretch Ascites (transudative) Jaundice Occasionally, hepatic ischemia Rarely, fulminant liver failure

Physical exam

Hepatomegaly with firm/smooth liver edge Splenomegaly uncommon JVD, HJR Pulsatile liver (or lack of)

Labs/Studies

Elevated bilirubin is most common finding (70%), usually unconjugated (3 mechanisms)

Hepatocellular dysfunction Hemolysis Biliary canicular obstruction 2/2 distended hepatic veins

Correlates with R atrial pressure Transaminases are usually mild, but can be extremely high if ischemia or necrosis Alkaline phosphatase mild Albumin, PT, Ammonia

Studies, contd

Ask about and examine for heart failure, tamponade, constrictive pericarditis Get a TTE and an ultrasound A normal TTE does not rule out congestive hepatopathy; more specific is dilation of all 3 hepatic veins on Liver U/S

Liver appearance and biopsy

Nutmeg liver Red from sinusoidal congestion and bleeding in necrotic regions; surrounded by yellow parenchyma from normal/fatty tissue Sinusoidal engorgement and hemorrhagic necrosis in perivenular areas Cholestasis with occ bile thrombi Cardiac fibrosis a bridging fibrosis, can regress histologically and clinically

Nutmeg liver

Zone 3 ischemia

Portal triad deliver blood to liver (portal vein, hepatic artery) and carry bile out (bile canaliculi) Central vein returns blood to heart Lobule surround central veins. Zone 1 most oxygenated; Zone 3 least oxygenated Zone 3 necrosis or centrilobular necrosis seen in passive congestion
http://www.vivo.colostate.edu/hbooks/pathphys/digestion/liver/histo_acinus.html

Zone 3 ischemia / centrilobular necrosis

http://pathology.class.kmu.edu.tw/ch03/24-3.jpg

Prognosis

Mortality usually due to cardiac disease, and the liver disease rarely contributes Cardiac cirrhosis rarely develop variceal bleeding or HCC.

Hepatic venous outflow obstruction

3 syndromes that fall under HVOO

1) veno-occlusive disease sinusoidal endothelial injury (transplant, chemo, XRT) 2) Budd-Chiari syndrome (thrombosis, compression, IVC web/cyst/abscess/tumor) 3) congestive hepatopathy

Bayraktar, et al. Hepatic venous outflow obstruction: Three similar syndromes. World J Gastroentrol 2007 Apr 7, 13(13), 1912-1927. http://pathology.class.kmu.edu.tw/ch03/24-3.jpg Bowen, R. http://www.vivo.colostate.edu/hbooks/pathphys/digestion/liver/histo_acinus.html