Hepatic Blood Flow Obstruction

Introduction

Due to dual blood supply the liver does not typically infarct Flow can be obstructed in 3 places pre-hepatic caused mainly by vessel thrombosis transplant rejection (hepatic artery)  polyarteritis nodosa (hepatic artery) pyelphlebitis (portal vein) hepatocellular carcinoma (portal vein) intra-hepatic causes cirrhosis Budd-Chiari syndrome/centrilobular hemorrhagic necrosis  ischemic sequelae of heart failure centrilobular region perfused last and is the first to infarct post-hepatic caused by thrombosis of hepatic vein due to malignancy invasion (e.g. hepatocellular carcinoma) polycythemia vera  hypercoagulable states (e.g. pregnancy) Budd-Chiari syndrome  occlusion of hepatic veins that causes blood to back up into the liver  can lead to centrilobular congestion and necrosis congestive liver disease can ensue with symptoms of: hepatomegaly ascites varices abdominal pain liver failure potential causes polycythemia vera CHF hepatocellular carcinoma postpartum state hypercoaguable state anything that causes hepatic vein thrombosis pathological findings classicaly described as a "nutmeg liver" treatment sodium restriction anticoagulation: heparin warfarin surgical shunts liver transplanation in patient with fluminant liver failure recurrence of disease is common

Presentation

Physical exam pre-hepatic portal hypertension ascites NO hepatomegaly intra-hepatic hepatomegaly portal hypertension ascites post-hepatic hepatomegaly portal hypertension ascites

Evaluation

Intra-hepatic liver biopsy "nutmeg" appearance secondary to blood congestion/necrosis around central veins labs ↑ transaminases Post-hepatic ultrasound is test of choice labs ↑ transaminases

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