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Hypoxic Hepatitis

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Vascular Disorders of the Liver

Abstract

Hypoxic hepatitis (HH), also known as ischemic hepatitis or shock liver, is an acute liver injury caused by liver ischemia. Common underlying conditions that lead to hypoxic hepatitis are cardiac failure, respiratory failure and septic shock. The most significant distinguishing features are a massive, rapid but transient elevation of serum aspartate transaminase (AST) and alanine transaminase (ALT), and the reversal of the original AST/ALT ratio during the declining phase of enzyme changes. Around 50% of patients with HH do not have a documented hypotensive event or shock state and therefore, “shock liver” is not a proper term for these patients. In patients with toxic/septic shock, the oxygen supply to the liver is not decreased, but rather the increased oxygen requirement unbalances the oxygen supply/demand relationship. Thus, the septic liver is not truly “ischemic”. Accordingly, the term “ischemic hepatitis” is not strictly correct either. Hypoxic hepatitis is now the universally preferred term. The incidence of hypoxic hepatitis is 0.2% of total hospital admissions and 1.5–11% in patients in intensive care units. The pathophysiology is multifactorial and includes hepatic congestion due to right heart failure (backward failure) along with decreased hepatic perfusion (forward failure); hypoxemia due to respiratory diseases, reduced oxygen uptake by hepatocytes, and reperfusion injury. The diagnostic criteria include: a compatible clinical setting, such as cardiac, circulatory or respiratory failure; abrupt, significant, but transient rise in serum aminotransferase levels; and exclusion of other causes of hepatocellular necrosis. The therapeutic strategies are mostly supportive including correcting the underlying disease state, avoiding potential complications such as hypoglycemia, hyperglycemia, hyperammonemia and hepatopulmonary syndrome. The mortality rate is more than 50%. High aminotransferases, LDH, PT-INR, arterial ammonia and jaundice are predictors for poor outcomes.

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References

  1. Tricot R, Benhamou JP, Guillemot R. Urbanczyk a: [hemodynamics of the cardiac liver]. Pathol Biol. 1962;10:1361–4.

    CAS  Google Scholar 

  2. Mirouze D, Michel H. The liver in heart failure (author’s transl). Gastroenterol Clin Biol. 1982;6(2):143–7.

    CAS  Google Scholar 

  3. Lee SS. ‘Foie cardiaque’: a new name for an old syndrome? Liver Int. 2008;28(6):755–6.

    Article  Google Scholar 

  4. Mallory FB. Necroses of the liver. J Med Res. 1901;6(1):264–80.

    CAS  Google Scholar 

  5. Bynum TE, Boitnott JK, Maddrey WC. Ischemic hepatitis. Dig Dis Sci. 1979;24(2):129–35.

    Article  CAS  Google Scholar 

  6. Myers RP, Cerini R, Sayegh R, Moreau R, Degott C, Lebrec D, Lee SS. Cardiac hepatopathy: clinical, hemodynamic, and histologic characteristics and correlations. Hepatology. 2003;37(2):393–400.

    Article  Google Scholar 

  7. Lightsey JM, Rockey DC. Current concepts in ischemic hepatitis. Curr Opin Gastroenterol. 2017;33(3):158–63.

    Article  Google Scholar 

  8. Hilscher MSW. Congestive hepatopathy. Clin Liver Dis. 2016;8(1):68–71.

    Article  Google Scholar 

  9. Van den Broecke A, Van Coile L, Decruyenaere A, Colpaert K, Benoit D, Van Vlierberghe H, Decruyenaere J. Epidemiology, causes, evolution and outcome in a single-center cohort of 1116 critically ill patients with hypoxic hepatitis. Ann Intensive Care. 2018;8(1):15.

    Article  Google Scholar 

  10. Ciobanu AO, Gherasim L. Ischemic hepatitis – Intercorrelated pathology. Maedica (Buchar). 2018;13(1):5–11.

    Article  Google Scholar 

  11. Jung C, Fuernau G, Eitel I, Desch S, Schuler G, Kelm M, Adams V, Thiele H. Incidence, laboratory detection and prognostic relevance of hypoxic hepatitis in cardiogenic shock. Clin Res Cardiol. 2017;106(5):341–9.

    Article  CAS  Google Scholar 

  12. Henrion J, Schapira M, Luwaert R, Colin L, Delannoy A, Heller FR. Hypoxic hepatitis: clinical and hemodynamic study in 142 consecutive cases. Medicine (Baltimore). 2003;82(6):392–406.

    Article  Google Scholar 

  13. Kamiyama T, Miyakawa H, Tajiri K, Marumo F, Sato C. Ischemic hepatitis in cirrhosis. Clinical features and prognostic implications. J Clin Gastroenterol. 1996;22(2):126–30.

    Article  CAS  Google Scholar 

  14. Henrion J, Schapira M, Heller FR. Ischemic hepatitis: the need for precise criteria. J Clin Gastroenterol. 1996;23(4):305.

    Article  CAS  Google Scholar 

  15. Henrion J. Hypoxic hepatitis. Liver Int. 2012;32(7):1039–52.

    Article  CAS  Google Scholar 

  16. Tapper EB, Sengupta N, Bonder A. The incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314–21.

    Article  Google Scholar 

  17. Aboelsoud MM, Javaid AI, Al-Qadi MO, Lewis JH. Hypoxic hepatitis – its biochemical profile, causes and risk factors of mortality in critically-ill patients: a cohort study of 565 patients. J Crit Care. 2017;41:9–15.

    Article  CAS  Google Scholar 

  18. Fuhrmann V, Kneidinger N, Herkner H, Heinz G, Nikfardjam M, Bojic A, Schellongowski P, Angermayr B, Schoniger-Hekele M, Madl C, et al. Impact of hypoxic hepatitis on mortality in the intensive care unit. Intensive Care Med. 2011;37(8):1302–10.

    Article  Google Scholar 

  19. Drolz A, Saxa R, Scherzer T, Fuhrmann V. Extracorporeal artificial liver support in hypoxic liver injury. Liver Int. 2011;31(Suppl 3):19–23.

    Article  Google Scholar 

  20. Eipel C, Abshagen K, Vollmar B. Regulation of hepatic blood flow: the hepatic arterial buffer response revisited. World J Gastroenterol. 2010;16(48):6046–57.

    Article  Google Scholar 

  21. Vollmar B, Menger MD. The hepatic microcirculation: mechanistic contributions and therapeutic targets in liver injury and repair. Physiol Rev. 2009;89(4):1269–339.

    Article  CAS  Google Scholar 

  22. Vernon H, Kasi A. Anatomy, abdomen, liver. Treasure Island, FL: StatPearls; 2018.

    Google Scholar 

  23. Waseem N, Chen PH. Hypoxic hepatitis: a review and clinical update. J Clin Transl Hepatol. 2016;4(3):263–8.

    Google Scholar 

  24. Lautt WW. Mechanism and role of intrinsic regulation of hepatic arterial blood flow: hepatic arterial buffer response. Am J Phys. 1985;249(5 Pt 1):G549–56.

    CAS  Google Scholar 

  25. Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: clinical presentation and pathogenesis. Am J Med. 2000;109(2):109–13.

    Article  CAS  Google Scholar 

  26. Krejci V, Hiltebrand LB, Sigurdsson GH. Effects of epinephrine, norepinephrine, and phenylephrine on microcirculatory blood flow in the gastrointestinal tract in sepsis. Crit Care Med. 2006;34(5):1456–63.

    Article  CAS  Google Scholar 

  27. Aninat C, Seguin P, Descheemaeker PN, Morel F, Malledant Y, Guillouzo A. Catecholamines induce an inflammatory response in human hepatocytes. Crit Care Med. 2008;36(3):848–54.

    Article  CAS  Google Scholar 

  28. Edwards JD. Oxygen transport in cardiogenic and septic shock. Crit Care Med. 1991;19(5):658–63.

    Article  CAS  Google Scholar 

  29. Rudiger A, Singer M. Mechanisms of sepsis-induced cardiac dysfunction. Crit Care Med. 2007;35(6):1599–608.

    Article  Google Scholar 

  30. Wanless IR, Wong F, Blendis LM, Greig P, Heathcote EJ, Levy G. Hepatic and portal vein thrombosis in cirrhosis: possible role in development of parenchymal extinction and portal hypertension. Hepatology. 1995;21(5):1238–47.

    CAS  Google Scholar 

  31. Moreau R, Lee SS, Soupison T, Roche-Sicot J, Sicot C. Abnormal tissue oxygenation in patients with cirrhosis and liver failure. J Hepatol. 1988;7(1):98–105.

    Article  CAS  Google Scholar 

  32. Chang PE, Goh BG, Ekstrom V, Ong ML, Tan CK. Low serum albumin predicts early mortality in patients with severe hypoxic hepatitis. World J Hepatol. 2017;9(22):959–66.

    Article  Google Scholar 

  33. Taylor RM, Tujios S, Jinjuvadia K, Davern T, Shaikh OS, Han S, Chung RT, Lee WM, Fontana RJ. Short and long-term outcomes in patients with acute liver failure due to ischemic hepatitis. Dig Dis Sci. 2012;57(3):777–85.

    Article  Google Scholar 

  34. Mohacsi P, Meier B. Hypoxic hepatitis in patients with cardiac failure. J Hepatol. 1994;21(5):693–5.

    Article  CAS  Google Scholar 

  35. Henrion J, Descamps O, Luwaert R, Schapira M, Parfonry A, Heller F. Hypoxic hepatitis in patients with cardiac failure: incidence in a coronary care unit and measurement of hepatic blood flow. J Hepatol. 1994;21(5):696–703.

    Article  CAS  Google Scholar 

  36. Fuhrmann V, Jager B, Zubkova A, Drolz A. Hypoxic hepatitis – epidemiology, pathophysiology and clinical management. Wien Klin Wochenschr. 2010;122(5–6):129–39.

    Article  Google Scholar 

  37. Henrion J, Minette P, Colin L, Schapira M, Delannoy A, Heller FR. Hypoxic hepatitis caused by acute exacerbation of chronic respiratory failure: a case-controlled, hemodynamic study of 17 consecutive cases. Hepatology. 1999;29(2):427–33.

    Article  CAS  Google Scholar 

  38. Ucgun I, Ozakyol A, Metintas M, Moral H, Orman A, Bal C, Yildirim H. Relationship between hypoxic hepatitis and cor pulmonale in patients treated in the respiratory ICU. Int J Clin Pract. 2005;59(11):1295–300.

    Article  CAS  Google Scholar 

  39. Mathurin P, Durand F, Ganne N, Mollo JL, Lebrec D, Degott C, Erlinger S, Benhamou JP, Bernuau J. Ischemic hepatitis due to obstructive sleep apnea. Gastroenterology. 1995;109(5):1682–4.

    Article  CAS  Google Scholar 

  40. Henrion J, Colin L, Schapira M, Heller FR. Hypoxic hepatitis caused by severe hypoxemia from obstructive sleep apnea. J Clin Gastroenterol. 1997;24(4):245–9.

    Article  CAS  Google Scholar 

  41. Fuhrmann V, Kneidinger N, Herkner H, Heinz G, Nikfardjam M, Bojic A, Schellongowski P, Angermayr B, Kitzberger R, Warszawska J, et al. Hypoxic hepatitis: underlying conditions and risk factors for mortality in critically ill patients. Intensive Care Med. 2009;35(8):1397–405.

    Article  Google Scholar 

  42. Drolz A, Jager B, Wewalka M, Saxa R, Horvatits T, Roedl K, Perkmann T, Zauner C, Kramer L, Ferenci P, et al. Clinical impact of arterial ammonia levels in ICU patients with different liver diseases. Intensive Care Med. 2013;39(7):1227–37.

    Article  CAS  Google Scholar 

  43. Trilok G, Qing YC, Li-Jun X. Hypoxic hepatitis: a challenging diagnosis. Hepatol Int. 2012;6(4):663–9.

    Article  Google Scholar 

  44. Raurich JM, Perez O, Llompart-Pou JA, Ibanez J, Ayestaran I, Perez-Barcena J. Incidence and outcome of ischemic hepatitis complicating septic shock. Hepatol Res. 2009;39(7):700–5.

    Article  Google Scholar 

  45. Gitlin N, Serio KM. Ischemic hepatitis: widening horizons. Am J Gastroenterol. 1992;87(7):831–6.

    CAS  Google Scholar 

  46. Acharya SK, Bhatia V, Sreenivas V, Khanal S, Panda SK. Efficacy of L-ornithine L-aspartate in acute liver failure: a double-blind, randomized, placebo-controlled study. Gastroenterology. 2009;136(7):2159–68.

    Article  CAS  Google Scholar 

  47. Jager B, Drolz A, Michl B, Schellongowski P, Bojic A, Nikfardjam M, Zauner C, Heinz G, Trauner M, Fuhrmann V. Jaundice increases the rate of complications and one-year mortality in patients with hypoxic hepatitis. Hepatology. 2012;56(6):2297–304.

    Article  Google Scholar 

  48. Kneidinger N, Funk GC, Lindner G, Drolz A, Schenk P, Fuhrmann V. Unmeasured anions are associated with short-term mortality in patients with hypoxic hepatitis. Wien Klin Wochenschr. 2013;125(15–16):474–80.

    Article  Google Scholar 

  49. Horvatits T, Kneidinger N, Drolz A, Roedl K, Rutter K, Kluge S, Trauner M, Fuhrmann V. Prognostic impact of ICG-PDR in patients with hypoxic hepatitis. Ann Intensive Care. 2015;5(1):47.

    Article  Google Scholar 

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Authors and Affiliations

  1. Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada

    Hongqun Liu & Samuel S. Lee

  2. Division of Gastroenterology, Pusan National University Yangsan Hospital, Yangsan, South Korea

    Ki Tae Yoon

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  1. Hongqun Liu
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  2. Ki Tae Yoon
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  3. Samuel S. Lee
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Correspondence to Samuel S. Lee .

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Editors and Affiliations

  1. CRI, UMR 1149, Université de Paris and Inserm, Paris, France

    Dominique Valla

  2. Hospital Clinic, Hepatic Hemodynamic Lab Hospital Clinic, Barcelona, Spain

    Juan Carlos Garcia-Pagan

  3. Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Lugano, Switzerland

    Andrea De Gottardi

  4. Université de Paris, Paris, France

    Pierre-Emmanuel Rautou

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Liu, H., Yoon, K.T., Lee, S.S. (2022). Hypoxic Hepatitis. In: Valla, D., Garcia-Pagan, J.C., De Gottardi, A., Rautou, PE. (eds) Vascular Disorders of the Liver . Springer, Cham. https://doi.org/10.1007/978-3-030-82988-9_12

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  • DOI: https://doi.org/10.1007/978-3-030-82988-9_12

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  • Online ISBN: 978-3-030-82988-9

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