From the Guidelines
Shock liver, also known as ischemic hepatitis, is a condition where the liver experiences sudden, severe damage due to reduced blood flow and oxygen supply, typically occurring during periods of significant cardiovascular instability, such as during shock or heart failure, as described in the AASLD position paper on the management of acute liver failure 1. Key points about shock liver:
- Causes: Most commonly results from cardiogenic shock, septic shock, or severe hypotension, and can also be caused by drug-induced hypotension or hypoperfusion, such as with long-acting niacin, cocaine, or methamphetamine 1.
- Symptoms: Often asymptomatic initially, but can progress to jaundice, confusion, and abdominal pain, with evidence of cardiac dysfunction potentially elicited via echocardiogram 1.
- Diagnosis: Characterized by a rapid and dramatic increase in liver enzymes (AST and ALT), often rising to levels that are markedly elevated and respond rapidly to stabilization of the circulatory problem 1.
- Treatment: Focuses on addressing the underlying cause of shock and supporting liver function, with the ability to manage heart failure or other causes of ischemia successfully determining outcome for these patients, and transplantation seldom indicated 1.
- Prognosis: Generally reversible if the underlying cause is promptly addressed, but mortality can be high due to the severity of the underlying condition.
- Monitoring: Regular liver function tests and close clinical observation are essential during treatment and recovery, with simultaneous onset of renal dysfunction and muscle necrosis potentially noted 1. Understanding shock liver is crucial because it highlights the liver's vulnerability to systemic circulatory issues and emphasizes the importance of maintaining adequate organ perfusion in critically ill patients, with early recognition and aggressive treatment of the underlying shock state being key to preventing permanent liver damage and improving overall outcomes.
From the Research
Definition and Characteristics of Shock Liver
- Shock liver, also known as ischemic hepatitis or hypoxic hepatitis, is a condition characterized by centrilobular liver cell necrosis and sharply increasing serum aminotransferase levels in a clinical setting of cardiac, circulatory, or respiratory failure 2, 3, 4.
- It is frequently observed in intensive care units, with a reported prevalence of up to 10% 3.
- The condition is caused by a lack of oxygen to the liver, which can be due to various factors such as low cardiac output, septic shock, or respiratory failure 3, 4.
Pathophysiology and Underlying Conditions
- The underlying pathophysiology involves changes in the portal and arterial blood supply, as well as in microcirculation 2.
- Cross-talk between hepatocytes, Kupffer cells, and endothelial cells leads to an inflammatory response mediated primarily by tumour necrosis factor-alpha (TNF-alpha) 2.
- The main underlying conditions contributing to shock liver are low cardiac output and septic shock, although a multifactorial etiology is found in the majority of patients 3, 4.
Clinical Management and Prognosis
- The management of shock liver is focused on the prevention of precipitating causes by controlling sepsis, circulation parameters, and metabolism, in addition to cautious monitoring of therapeutic measures that can increase hepatic injury 2.
- Early recognition of shock liver and its underlying diseases, and subsequent initiation of therapy, is of central prognostic importance 3, 5.
- The prognosis is poor, with more than half of patients dying during the hospital stay 4.