Updated: 1/16/2018

Hepatic Blood Flow Obstruction

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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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