What is the management of a liver infarct?

Management of Liver Infarct

The management of liver infarct should focus on supportive care, monitoring for complications, and addressing the underlying cause, with non-operative management being the preferred approach in hemodynamically stable patients.

Diagnosis

• CT scan with intravenous contrast is the gold standard for diagnosis of liver infarct in hemodynamically stable patients 1
• MRI and ultrasound can be used for follow-up imaging to monitor healing and complications 2, 3
• Liver infarcts may appear as:
  • Round or oval centrally located lesions
  • Wedge-shaped peripheral lesions
  • Initially poorly demarcated low-density regions on CT that later become more distinct 4

Initial Management

Hemodynamic Stabilization

• For hemodynamically unstable patients:
  • Immediate fluid resuscitation with balanced crystalloids and/or albumin
  • Norepinephrine (0.01–0.5 μg/kg/min) as first-line vasopressor if fluid resuscitation fails
  • Vasopressin as potential second-line agent 5
  • Consider operative management if instability persists 1

Non-Operative Management (NOM)

• NOM should be the treatment of choice for all hemodynamically stable patients 1
• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status 1
• Monitor for:
  • Encephalopathy: Frequent monitoring, Glasgow Coma Scale
  • Coagulopathy: Restrict clotting factor administration to cases with active bleeding
  • Renal dysfunction: Monitor serum sodium, avoid nephrotoxic agents 5

Management of Complications

Bleeding Complications

• Delayed hemorrhage without severe hemodynamic compromise may be managed with angiography/angioembolization (AG/AE) 1
• Hepatic artery pseudoaneurysm should be managed with AG/AE to prevent rupture 1

Infectious Complications

• Intrahepatic abscesses may be successfully treated with percutaneous drainage 1
• Monitor for signs of infection (fever, leukocytosis, increasing pain)

Biliary Complications

• Symptomatic or infected bilomas should be managed with percutaneous drainage 1
• Combination of percutaneous drainage and endoscopic techniques may be considered for post-traumatic biliary complications 1
• Laparoscopic lavage/drainage and endoscopic stenting may be considered for delayed post-traumatic biliary fistula 1

Thromboprophylaxis and Supportive Care

• Mechanical prophylaxis is safe and should be considered in all patients without absolute contraindication 1
• LMWH-based prophylaxis should be started as soon as possible when the patient is stabilized 1, 5
• In patients taking anticoagulants, individualization of the risk-benefit balance of anticoagulant reversal is necessary 1
• Early mobilization should be achieved in stable patients 1
• In the absence of contraindications, enteral feeding should be started as soon as possible 1
  • Approximately 60 grams of protein per day is reasonable 5

Follow-up Care

• Mandatory late follow-up imaging is not indicated and should be used only if clinical condition or symptoms suggest a complication 1
• Most liver lesions heal in approximately 4 months 1
• Normal physical activities may be resumed after 3-4 months following moderate to severe liver injuries 1
• If CT scan follow-up shows significant healing, normal activity can be resumed even after 1 month 1
• Patients should be advised to:
  • Not remain alone for long periods
  • Return immediately to the hospital if experiencing increasing abdominal pain, lightheadedness, nausea, or vomiting 1

Special Considerations

• Liver infarcts are rare due to the dual blood supply (hepatic artery and portal vein), but can occur when both vessels are compromised or when collateral arterial supply is affected 6, 7
• Common causes of liver infarcts include infected emboli, polyarteritis nodosa, trauma with TAE, and as a complication of liver transplantation 6, 2, 7
• In cases of large devitalized liver portions, delayed hepatic resection may be considered, but only in centers with necessary expertise 1