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Updated: Jan 16 2018

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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