What is the treatment for hepatic infarct?

Treatment of Hepatic Infarction

The treatment of hepatic infarction should focus on addressing the underlying cause while providing supportive care, with management strategies including anticoagulation for thrombotic causes, transarterial therapies for appropriate cases, and intensive medical support for organ dysfunction.

Diagnosis and Initial Assessment

• Confirm hepatic infarction with contrast-enhanced imaging (4-phase multidetector CT or dynamic contrast-enhanced MRI) 1
• Hepatic infarcts typically appear as hypodense parenchymal areas, sometimes triangular in shape with sharp peripheral contours, or as rounded central/marginal areas 2
• Assess for underlying causes:
  • Arterial causes (most common - 85% of cases) 2
  • Portal vein thrombosis
  • Systemic circulatory insufficiency
  • Post-procedural complications (embolization, chemoembolization)
  • Liver transplant-related complications

Treatment Approach Based on Etiology

1. Thrombotic/Embolic Causes

• Initiate anticoagulation therapy in cases of thromboembolism, particularly when portal vein thrombosis is identified 3
• For portal vein thrombosis:
  • Begin anticoagulation promptly in the absence of major contraindications
  • Brief interruption of anticoagulation may be considered when invasive procedures are performed 3
  • Monitor closely for early detection of liver deterioration

2. Post-procedural Infarction

• For infarction following transarterial procedures (embolization, chemoembolization):
  • Provide supportive care
  • Consider angioplasty/stenting as first-line decompressive procedure in patients with venous stenosis 3

3. Vascular Malformations

• For hepatic infarction related to vascular malformations:
  • Intensive medical treatment for high-output cardiac failure (salt restriction, diuretics, beta blockers, digoxin, ACE inhibitors) 3
  • Treat complications of portal hypertension as recommended in cirrhotic patients
  • Consider orthotopic liver transplantation for ischemic biliary necrosis, intractable heart failure, or complicated portal hypertension 3

Supportive Care Measures

• Fluid and electrolyte management to maintain adequate perfusion while avoiding fluid overload
• Pain control with acetaminophen (up to 3g/day) as first-line therapy; avoid NSAIDs due to risk of gastrointestinal bleeding and nephrotoxicity 3
• If moderate-to-severe pain persists, opioids may be used with concurrent laxative therapy to prevent constipation and hepatic encephalopathy 3
• Nutritional support for patients with weight loss and muscle wasting 3

Management of Complications

Hepatic Failure

• For patients with acute liver failure secondary to hepatic infarction:
  • Intensive care management with monitoring of cerebral edema, fluid status, and prevention of sepsis 4
  • Consider continuous renal replacement therapy if renal dysfunction develops
  • Early and intensive therapy with heparin and fresh frozen plasma if evidence of intravascular coagulation is present 5

Portal Hypertension Complications

• Treat complications of portal hypertension (bleeding from gastroesophageal varices, ascites) as recommended for cirrhotic patients 3
• Note that transjugular intrahepatic portosystemic shunt (TIPS) may not be helpful in the setting of vascular malformations and could worsen hyperdynamic circulation 3

Advanced Interventions

• Transarterial therapies may be considered for appropriate cases:

  • Transarterial embolization (TAE) for unresectable lesions with adequate hepatic functional reserve 3
  • Use caution with transarterial procedures in patients with portosystemic shunts 3

• Liver transplantation should be considered as a salvage treatment for patients in whom other techniques have failed 3

  • Particularly indicated for ischemic biliary necrosis, intractable high-output cardiac failure, and complicated portal hypertension 3

Follow-up and Monitoring

• Regular imaging follow-up to assess resolution or progression of infarction
• Monitor liver function tests to evaluate recovery
• Seek expert hepatology advice for complex cases, especially when considering liver transplantation 3

Caveats and Pitfalls

• Liver biopsy should generally be avoided in patients with suspected vascular malformations due to high risk of bleeding 3
• Transarterial embolization carries significant risk (10% fatal complications) and should be used cautiously 3
• Early recognition and treatment of intravascular coagulation is critical before the onset of major gastrointestinal bleeding 5
• The dual blood supply of the liver (hepatic artery and portal vein) means complete infarction is uncommon, but can occur with simultaneous compromise of both vascular systems 6, 7