University of Iowa Hospitals & Clinics Iowa City, IA, United States
Dustin J. Uhlenhopp, DO1, Eric O. Then, MD2, Andrew Popp, MD3, Jay P. Babich, MD3, Vinaya Gaduputi, MD3 1University of Iowa Hospitals & Clinics, Iowa City, IA; 2The Brooklyn Hospital Center, Brooklyn, NY; 3Blanchard Valley Health System, Findlay, OH
Introduction: Ischemic hepatitis is a rare cause of acute liver injury and has a 30-day morality rate as high as 50% and a one-year survival rate of approximately 28%. Causes of ischemic hepatitis are most often cardiac in origin due to arrhythmias, myocardial infarction, heart failure, or tamponade. Early identification of the underlying etiology in ischemic hepatitis is key for survival.
Case Description/Methods: A 64-year-old Caucasian female with past medical history of lupus on hydroxychloroquine, hypothyroidism, COPD, and previous stroke presented with a complaint of persistent, severe abdominal pain with nausea, emesis, and malaise for the past 5 days. She denied heavy alcohol, illicit drug use, or tattoos.
She was hypotensive on presentation but initially responded to IV fluid resuscitation. She was afebrile and saturating well on room air. She had diffuse, mild-to-moderate abdominal tenderness to palpation. Labs were significant for hyponatremia and slightly elevated AST/ALT (133 and 151 U/L respectively). SARS-CoV-2 PCR was negative. Troponin was normal. CT scan with IV contrast of the abdomen/pelvis demonstrated a large pericardial effusion, measuring 2 cm suggestive of possible hemorrhage with prominent mediastinal and upper abdominal adenopathy concerning for lymphoma.
Over the next 24 hours, the patient required pressor support and AST/ALT levels increased to >52,000 U/L. Liver sonogram with duplex was negative for hepatic/portal vein thrombosis. Hepatitis panel was non-reactive. She underwent urgent pericardiocentesis. Repeat CT scan showed small amount of air in the pericardial space from recent drainage. On day 5 after pericardiocentesis, AST/ALT improved to 64 and 552 U/L respectively.
The etiology of this patient’s pericardial effusion remains unclear. Cytology, cultures and additional infectious workup was negative. Autoimmune studies, in the setting of known lupus and hypothyroidism, were negative. Additional malignancy workup is currently underway.
Discussion: We present a rare case of ischemic hepatitis caused by an atypical presentation of pericardial tamponade. Pericardiocentesis lead to resolution of the patient’s liver injury. This case emphasizes the need for proper workup in any patient presenting with symptoms suggestive of acute hepatitis, including abdominal pain, nausea, emesis, and malaise. Serum transaminases typically returns to baselines levels within 10 days of treating the underlying cause.
Figure: CT scan of the abdomen/pelvis demonstrating a large, high-attenuation pericardial effusion (yellow arrow) that lead to hemodynamic compromise and ischemic hepatitis within 24 hours of presentation for severe abdominal pain [A]. A small amount of air (yellow arrowhead) can be seen in the pericardial space following pericardial drainage, which is not an unusual finding post-procedure [B].
Dustin Uhlenhopp indicated no relevant financial relationships.
Eric Then indicated no relevant financial relationships.
Andrew Popp indicated no relevant financial relationships.
Jay Babich indicated no relevant financial relationships.
Vinaya Gaduputi indicated no relevant financial relationships.
Dustin J. Uhlenhopp, DO1, Eric O. Then, MD2, Andrew Popp, MD3, Jay P. Babich, MD3, Vinaya Gaduputi, MD3. P0783 - Cardiac Tamponade as a Rare Cause of Shock Liver, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.