Clinical Case Summary

Introduction: Ischemic hepatitis or shock liver is an acute liver injury resulting from hepatic hypoperfusion. It is defined by a massive and reversible elevation of aminotransferases of at least 20 times the upper normal limit, excluding any other cause of acute hepatitis. We report the case of ischemic hepatitis occurring during acute ischemia of the lower limbs. Hepatic congestion secondary to heart dysfunction could be a predisposing condition for the development of ischemic hepatitis.
Case presentation: A 67-year-old man admitted to the ICU for management of acute ischemia of the lower limbs. Past history included high blood pressure, insulin-treated diabetes, and chronic tobacco. His left lower limb had been painful for more than 4 days. Arterial ischemia was recognized and an amputation was carried out the same day. The patient was jaundiced with hepatomegaly on abdominal examination. There were no clinical signs of respiratory failure. Laboratory tests showed aminotransferase levels rapidly increasing at least 50 times the upper normal limit. A low prothrombin count of 35% was present. Other causes of liver disease were excluded. The cardiac evaluation had concluded in congestive heart failure with LV ejection fraction at 25% associated with left intra-auricular thrombus. After vascular surgery and therapeutic adjustment for his cardiac pathology, a normalization of liver function tests was marked within 10 days.
Conclusion: Ischemic hepatitis is a cause of acute cytolysis to be considered in a patient with heart failure. Acute lower limb ischemia should be added to the list of conditions that can trigger ischemic hepatitis. In this particular context, an urgent amputation of the ischemic limb was a necessary condition for survival.

References

- Ischemic hepatitis: a cause of acute cytolysis that should not be overlooked. N. Regaieg, C. Damak, D. Chebbi, I. Chabchoub, F. Frikha, Z. Bahloul. https://doi.org/10.1016/j.revmed.2021.10.105
- A case of ischemic hepatitis Georgia Trakada¹, Charis Gogos, Maria Tsiamita, Dimitris Siagris, Panagiotis Goumas, Kostas Spiropoulos DOI: 10.1007/s11325-004-0155-7
- Acute lower limb ischemia as a triggering condition in hypoxic hepatitis: a study of five cases Jean Henrion¹, Pierre Deltenre, Stéphane De Maeght, Marie-Odile Peny, Michael Schapira. DOI: 10.1097/MCG.0b013e3181dad995