History

Fact Explanation
A predisposing condition The commonest predisposing conditions are the diseases of the right heart. i.e. right heart failure due to pulmonary hypertension, congestive cardiac failure. The reason behind congestive hepatopathy being a result of right heart failure is that, since the back pressure of systemic veins, venous blood is congested in the liver and there is a chronic ischemia going on if the congestion keeps on for a long time. [1] [2] [3] [4] [5]
Sense of fullness in the upper abdomen Due to hepatomegaly in congestion. [6] [7]
Upper abdominal pain Due to the stretching of the liver capsule. [6]
Coughing out blood stained sputum Due to pulmonary venous congestion due to left sided heart failure. [8] [9]
Yellow discoloration of eyes, pale stools and dark urine Not common, and due to periportal necrosis and centrilobular fibrosis. [6] [10]
Swelling of the abdomen Cirrhosis is rare but present due to long standing congestion. [3] [4] [10] [11] [12]
Swelling of the abdomen Cirrhosis is rare but present due to long standing congestion. [3] [4] [10] [11] [12]
Features of right heart failure i.e. Dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, reduced exercise tolerance, lethargy, fatigue, nocturnal cough, wheeze, ankle swelling, anorexia. [13]
References
  1. FOUAD YM, YEHIA R. Hepato-cardiac disorders World J Hepatol [online] 2014 Jan 27, 6(1):41-54 [viewed 11 August 2014] Available from: doi:10.4254/wjh.v6.i1.41
  2. SAFRAN AP, SCHAFFNER F. Chronic passive congestion of the liver in man. Electron microscopic study of cell atrophy and intralobular fibrosis. Am J Pathol [online] 1967 Mar, 50(3):447-63 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6018673
  3. MOLLER S., BERNARDI M.. Interactions of the heart and the liver. European Heart Journal [online] December, 34(36):2804-2811 [viewed 11 August 2014] Available from: doi:10.1093/eurheartj/eht246
  4. MøLLER SøREN, DüMCKE CHRISTINE WINKLER, KRAG ALEKSANDER. The heart and the liver. Expert Review of Gastroenterology & Hepatology [online] 2009 February, 3(1):51-64 [viewed 11 August 2014] Available from: doi:10.1586/17474124.3.1.51
  5. NASCHITZ JOCHANAN E., SLOBODIN GLEB, LEWIS ROGER J., ZUCKERMAN ELIMELECH, YESHURUN DANIEL. Heart diseases affecting the liver and liver diseases affecting the heart. American Heart Journal [online] 2000 July, 140(1):111-120 [viewed 11 August 2014] Available from: doi:10.1067/mhj.2000.107177
  6. ALVAREZ ALICIA, MUKHERJEE DEBABRATA. Liver Abnormalities in Cardiac Diseases and Heart Failure. Int J Angiol [online] December, 20(03):135-142 [viewed 12 August 2014] Available from: doi:10.1055/s-0031-1284434
  7. BRUCE C. J., CONNOLLY H. M.. Right-Sided Valve Disease Deserves a Little More Respect. Circulation [online] December, 119(20):2726-2734 [viewed 12 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.108.776021
  8. CHANG JC, CREGLER LL. Hemoptysis in a patient with congestive heart failure and pulmonary emboli. J Natl Med Assoc [online] 1994 May, 86(5):383-386 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607681
  9. BIDWELL JL et al. Hemoptysis: Diagnosis and Management. Am Fam Physician. [online] 2005 Oct 1;72(7):1253-1260. [viewed 12 August 2014] Available from http://www.aafp.org/afp/2005/1001/p1253.html
  10. MYERS R. Cardiac hepatopathy: Clinical, hemodynamic, and histologic characteristics and correlations. Hepatology [online] 2003 February, 37(2):393-400 [viewed 12 August 2014] Available from: doi:10.1053/jhep.2003.50062
  11. Cirrhosis and Heart Failure Postgrad Med J [online] 1951 May, 27(307):247-253 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2530312
  12. BLUMGART HL, KATZIN H. "Cardiac Cirrhosis" of the Liver: A Clinical and Pathological Study Trans Am Clin Climatol Assoc [online] 1938:82-86 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2242083
  13. WATSON RD, GIBBS CR, LIP GY. Clinical features and complications BMJ [online] 2000 Jan 22, 320(7229):236-239 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117436

Examination

Fact Explanation
Icterus Due to hyperbilirubinemia in cirrhosis. [1] [2] [3] [4] [5]
Tender hepatomegaly Due to stretching of the liver capsule. [3]
Ascites Due sinusoidal portal hypertension and hepatic insufficiency in cirrhosis. [6] [7] [8] [9]
Features of right heart failure Look for signs of right heart failure. i.e. cachexia and muscle wasting, elevated jugular venous pressure, right ventricular heave, crepitations or wheeze, Tachycardia Pulsus alternans, edema. [10]
References
  1. MOLLER S., BERNARDI M.. Interactions of the heart and the liver. European Heart Journal [online] December, 34(36):2804-2811 [viewed 11 August 2014] Available from: doi:10.1093/eurheartj/eht246
  2. MøLLER SøREN, DüMCKE CHRISTINE WINKLER, KRAG ALEKSANDER. The heart and the liver. Expert Review of Gastroenterology & Hepatology [online] 2009 February, 3(1):51-64 [viewed 11 August 2014] Available from: doi:10.1586/17474124.3.1.51
  3. ALVAREZ ALICIA, MUKHERJEE DEBABRATA. Liver Abnormalities in Cardiac Diseases and Heart Failure. Int J Angiol [online] December, 20(03):135-142 [viewed 12 August 2014] Available from: doi:10.1055/s-0031-1284434
  4. Cirrhosis and Heart Failure Postgrad Med J [online] 1951 May, 27(307):247-253 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2530312
  5. BLUMGART HL, KATZIN H. "Cardiac Cirrhosis" of the Liver: A Clinical and Pathological Study Trans Am Clin Climatol Assoc [online] 1938:82-86 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2242083
  6. BRUCE C. J., CONNOLLY H. M.. Right-Sided Valve Disease Deserves a Little More Respect. Circulation [online] December, 119(20):2726-2734 [viewed 12 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.108.776021
  7. HOU WEI, SANYAL ARUN J.. Ascites: Diagnosis and Management. Medical Clinics of North America [online] 2009 July, 93(4):801-817 [viewed 12 August 2014] Available from: doi:10.1016/j.mcna.2009.03.007
  8. MOORE CM, VAN THIEL DH. Cirrhotic ascites review: Pathophysiology, diagnosis and management World J Hepatol [online] 2013 May 27, 5(5):251-263 [viewed 12 August 2014] Available from: doi:10.4254/wjh.v5.i5.251
  9. ROCCO VLTO K.. Cirrhotic Ascites. Ann Intern Med [online] 1986 October [viewed 12 August 2014] Available from: doi:10.7326/0003-4819-105-4-573
  10. WATSON RD, GIBBS CR, LIP GY. Clinical features and complications BMJ [online] 2000 Jan 22, 320(7229):236-239 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117436

Differential Diagnoses

Fact Explanation
Cirrhosis due to other reasons Should exclude cirrhosis due to other reasons. i.e. alcoholic cirrhosis, drug induced cirrhosis. They can mimic congestive hepatopathy since cirrhosis can lead to heart failure as well. [1] [2] [3] [4] [5] [6] [7] [8]
Portal hypertension One cause of portal hypertension is cirrhosis, but there are many others. The pre-hepatic (portal vein thrombosis), hepatic (WIlson disease, hemachromatosis, parasitic infections, autoimmune conditions) and post-hepatic (hepatic vein thrombosis, constrictive pericarditis) causes should be evaluated and excluded. The respective clinical evaluation with investigations should be carried out when deemed necessary. i.e. serum copper in Wilsons disease, ultrasound scan. [9] [10] [11] [12]
Cor-pulmonale Right ventricular failure due to pulmonary hypertension. The cause for increased pulmonary vascular resistance is usually evident (i.e. fibrosis, autoimmune diseases like scleroderma) and changes in the heart are also visible in echocardiography. (i.e. hypertrophy in chronic, dilation in acute) [13] [14] [15] [16]
References
  1. ISHAK KAMAL G., ZIMMERMAN HYMAN J., RAY MUKUNDA B.. Alcoholic Liver Disease: Pathologic, Pathogenetic and Clinical Aspects. Alcoholism Clin Exp Res [online] 1991 February, 15(1):45-66 [viewed 16 August 2014] Available from: doi:10.1111/j.1530-0277.1991.tb00518.x
  2. HABER PAUL S, WARNER ROSS, SETH DEVANSHI, GORRELL MARK D, MCCAUGHAN GEOFFREY W. Pathogenesis and management of alcoholic hepatitis. J Gastroenterol Hepatol [online] 2003 December, 18(12):1332-1344 [viewed 16 August 2014] Available from: doi:10.1046/j.1440-1746.2003.03217.x
  3. SOHDA TETSURO, SHIGA HIROSHI, NAKANE HIDETOSHI, NISHIZAWA SHINYA, YOSHIKANE MAKOTO, ANAN AKIRA, SUZUKI NORIHISA, IRIE MAKOTO, IWATA KAORU, WATANABE HIROSHI, SAKISAKA SHOTARO. Rapid-onset Primary Biliary Cirrhosis Resembling Drug-induced Liver Injury. Intern. Med. [online] 2005 December, 44(10):1051-1054 [viewed 16 August 2014] Available from: doi:10.2169/internalmedicine.44.1051
  4. RAJA KAISER, THUNG SWAN, FIEL M. ISABEL, CHANG CHARISSA. Drug-Induced Steatohepatitis Leading to Cirrhosis: Long-Term Toxicity of Amiodarone Use. Semin Liver Dis [online] December, 29(04):423-428 [viewed 16 August 2014] Available from: doi:10.1055/s-0029-1240011
  5. KAPLOWITZ N.. Drug-Induced Liver Injury. Clinical Infectious Diseases [online] 2004 March, 38(Supplement 2):S44-S48 [viewed 16 August 2014] Available from: doi:10.1086/381446
  6. HUSSAINI S HYDER, FARRINGTON ELIZABETH A. Idiosyncratic drug-induced liver injury: an overview. Expert Opin. Drug Saf. [online] 2007 November, 6(6):673-684 [viewed 16 August 2014] Available from: doi:10.1517/14740338.6.6.673
  7. SCHUPPAN DETLEF, AFDHAL NEZAM H. Liver cirrhosis. The Lancet [online] 2008 March, 371(9615):838-851 [viewed 16 August 2014] Available from: doi:10.1016/S0140-6736(08)60383-9
  8. PINZANI MASSIMO, ROSSELLI MATTEO, ZUCKERMANN MICHELE. Liver cirrhosis. Best Practice & Research Clinical Gastroenterology [online] 2011 April, 25(2):281-290 [viewed 16 August 2014] Available from: doi:10.1016/j.bpg.2011.02.009
  9. CICHOZ-LACH H, CELIńSKI K, SłOMKA M, KASZTELAN-SZCZERBIńSKA B. Pathophysiology of portal hypertension. J Physiol Pharmacol [online] 2008 Aug:231-8 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18812641
  10. GOEL A, MADHU K, ZACHARIAH U, SAJITH KG, RAMACHANDRAN J, RAMAKRISHNA B, GIBIKOTE S, JUDE J, CHANDY GM, ELIAS E, EAPEN CE. A study of aetiology of portal hypertension in adults (including the elderly) at a tertiary centre in southern India Indian J Med Res [online] 2013 May, 137(5):922-927 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734684
  11. MCDERMOTT WV JR. Portal Hypertension Secondary to Pancreatic Disease Ann Surg [online] 1960 Jul, 152(1):147-150 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613614
  12. AL-NAKSHABANDI NIZARA. The role of ultrasonography in portal hypertension. Saudi J Gastroenterol [online] 2006 December [viewed 16 August 2014] Available from: doi:10.4103/1319-3767.29750
  13. WEITZENBLUM E, CHAOUAT A. Cor pulmonale. Chronic Respiratory Disease [online] December, 6(3):177-185 [viewed 16 August 2014] Available from: doi:10.1177/1479972309104664
  14. SHUJAAT A, MINKIN R, EDEN E. Pulmonary hypertension and chronic cor pulmonale in COPD Int J Chron Obstruct Pulmon Dis [online] 2007 Sep, 2(3):273-282 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695205
  15. RUBIN LEWIS J.. Cor Pulmonale Revisited. Journal of the American College of Cardiology [online] 2013 September, 62(12):1112-1113 [viewed 16 August 2014] Available from: doi:10.1016/j.jacc.2013.06.034
  16. JARDIN FRANçOIS, VIEILLARD-BARON ANTOINE. Acute cor pulmonale. Current Opinion in Critical Care [online] 2009 February, 15(1):67-70 [viewed 16 August 2014] Available from: doi:10.1097/MCC.0b013e3283220ddd

Investigations - for Diagnosis

Fact Explanation
Liver function tests i.e. Transaminases, bilirubin, alkaline phasphatase, gamma GT: all of those can be mildly elevated with low serum albumin in cardiac cirrhosis. [1] [2] [3] [4]
Prothrombin time PT/INR is mildly elevated because of reduced synthesis of proteins from the liver. [5]
Echocardiography Can help in diagnosing the cardiac cause of liver failure. i.e. right heart ejection dysfunction. [5] [6] [7] [8] [9] [10]
Chest X-ray Look for evidence of cardiac dysfunction or pulmonary fibrosis. i.e. cardiomegaly [11] [12]
Histology The expected findings are centrilobular parenchymal atrophy, sinusoidal dilation, and perisinusoidal fibrosis. [8] [13] [14]
References
  1. SHERLOCK S. THE LIVER IN HEART FAILURE RELATION OF ANATOMICAL, FUNCTIONAL, AND CIRCULATORY CHANGES Br Heart J [online] 1951 Jul, 13(3):273-293 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC479419
  2. LIMDI J K. Evaluation of abnormal liver function tests. Postgraduate Medical Journal [online] 2003 June, 79(932):307-312 [viewed 16 August 2014] Available from: doi:10.1136/pmj.79.932.307
  3. ALLEN LARRY A., FELKER G. MICHAEL, POCOCK STUART, MCMURRAY JOHN J.V., PFEFFER MARC A., SWEDBERG KARL, WANG DUOLAO, YUSUF SALIM, MICHELSON ERIC L., GRANGER CHRISTOPHER B.. Liver function abnormalities and outcome in patients with chronic heart failure: data from the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program. European Journal of Heart Failure [online] December, 11(2):170-177 [viewed 16 August 2014] Available from: doi:10.1093/eurjhf/hfn031
  4. NASCHITZ JOCHANAN E., SLOBODIN GLEB, LEWIS ROGER J., ZUCKERMAN ELIMELECH, YESHURUN DANIEL. Heart diseases affecting the liver and liver diseases affecting the heart. American Heart Journal [online] 2000 July, 140(1):111-120 [viewed 16 August 2014] Available from: doi:10.1067/mhj.2000.107177
  5. FOUAD YM, YEHIA R. Hepato-cardiac disorders World J Hepatol [online] 2014 Jan 27, 6(1):41-54 [viewed 16 August 2014] Available from: doi:10.4254/wjh.v6.i1.41
  6. ROGERS J. H., BOLLING S. F.. The Tricuspid Valve: Current Perspective and Evolving Management of Tricuspid Regurgitation. Circulation [online] December, 119(20):2718-2725 [viewed 16 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.108.842773
  7. DAI DAO-FU, SWANSON PAUL E, KRIEGER ERIC V, LIOU IRIS W, CARITHERS ROBERT L, YEH MATTHEW M. Congestive hepatic fibrosis score: a novel histologic assessment of clinical severity. Mod Pathol [online] 2014 June [viewed 16 August 2014] Available from: doi:10.1038/modpathol.2014.79
  8. BAYRAKTAR U.D., SEREN S, BAYRAKTAR Y. Hepatic venous outflow obstruction: Three similar syndromes. World J Gastroenterol [online] 2007 April 7;13(13): 1912-1927 [viewed 16 August 2014] Available from: http://www.wjgnet.com/1007-9327/13/1912.asp
  9. LAUTEN A., DOENST T., HAMADANCHI A., FRANZ M., FIGULLA H. R.. Percutaneous Bicaval Valve Implantation for Transcatheter Treatment of Tricuspid Regurgitation: Clinical Observations and 12-Month Follow-Up. Circulation: Cardiovascular Interventions [online] December, 7(2):268-272 [viewed 16 August 2014] Available from: doi:10.1161/​CIRCINTERVENTIONS.113.001033
  10. MOLLER S., BERNARDI M.. Interactions of the heart and the liver. European Heart Journal [online] December, 34(36):2804-2811 [viewed 16 August 2014] Available from: doi:10.1093/eurheartj/eht246
  11. WEERAKKODY Y. Congestive hepatopathy. [web] [viewed 16 August 2014] Available from: http://radiopaedia.org/articles/congestive-hepatopathy
  12. LIN H-H, CHANG W-K, CHU H-C, CHAO Y-C, HSIEH T-Y. Hepatobiliary and pancreatic: Congestive hepatopathy. J Gastroenterol Hepatol [online] 2007 April, 22(4):593-593 [viewed 16 August 2014] Available from: doi:10.1111/j.1440-1746.2007.04885.x
  13. DAI DAO-FU, SWANSON PAUL E, KRIEGER ERIC V, LIOU IRIS W, CARITHERS ROBERT L, YEH MATTHEW M. Congestive hepatic fibrosis score: a novel histologic assessment of clinical severity. Mod Pathol [online] 2014 June [viewed 16 August 2014] Available from: doi:10.1038/modpathol.2014.79
  14. GHAFERI AMIR A., HUTCHINS GROVER M.. Progression of liver pathology in patients undergoing the Fontan procedure: Chronic passive congestion, cardiac cirrhosis, hepatic adenoma, and hepatocellular carcinoma. The Journal of Thoracic and Cardiovascular Surgery [online] 2005 June, 129(6):1348-1352 [viewed 16 August 2014] Available from: doi:10.1016/j.jtcvs.2004.10.005

Investigations - Fitness for Management

Fact Explanation
Complete blood count As preparation for procedures, anemia or thrombocytopenia should be corrected immediately before any procedures. [1] [2] [3]
References
  1. YOO BYUNG WON, CHOI JAE YOUNG, EUN LUCY YOUNGMIN, PARK HAN KI, PARK YOUNG HWAN, KIM SEUNG UP. Congestive hepatopathy after Fontan operation and related factors assessed by transient elastography. The Journal of Thoracic and Cardiovascular Surgery [online] 2014 April [viewed 17 August 2014] Available from: doi:10.1016/j.jtcvs.2014.04.010
  2. SHAMBAN . Significantly Elevated Liver Alkaline Phosphatase in Congestive Heart Failure. Gastroenterology Research [online] 2014 December [viewed 17 August 2014] Available from: doi:10.14740/gr600w
  3. HAPIRO MARTIN F.. Diagnostic Decision: The Complete Blood Count and Leukocyte Differential Count: An Approach to Their Rational Application. Ann Intern Med [online] 1987 January [viewed 08 June 2014] Available from: doi:10.7326/0003-4819-106-1-65

Management - General Measures

Fact Explanation
Educate the patient Educate the family and the patient about the condition, it's prognosis and the importance of adherence to treatments. [1] [2] [3]
Treat the underlying condition Treat the disease of the heart or lungs which predisposed the hepatopathy. i.e. congestive cardiac failure, pulmonary hypertension.
References
  1. JUENGER J, SCHELLBERG D, KRAEMER S, HAUNSTETTER A, ZUGCK C, HERZOG W, HAASS M. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables Heart [online] 2002 Mar, 87(3):235-241 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767036
  2. GOTTLIEB STEPHEN S., KOP WILLEM J., ELLIS STEPHEN J., BINKLEY PHILIP, HOWLETT JONATHAN, O'CONNOR CHRISTOPHER, BLUMENTHAL JAMES A., FLETCHER GERALD, SWANK ANN M., COOPER LAWTON. Relation of Depression to Severity of Illness in Heart Failure (from Heart Failure And a Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION]). The American Journal of Cardiology [online] 2009 May, 103(9):1285-1289 [viewed 17 August 2014] Available from: doi:10.1016/j.amjcard.2009.01.025
  3. YOUNOSSI ZM, BOPARAI N, PRICE LL, KIWI ML, MCCORMICK M, GUYATT G. Health-related quality of life in chronic liver disease: the impact of type and severity of disease. Am J Gastroenterol [online] 2001 Jul, 96(7):2199-205 [viewed 17 August 2014] Available from: doi:10.1111/j.1572-0241.2001.03956.x

Management - Specific Treatments

Fact Explanation
Salt restriction There is a positive sodium balance in heart failure and cirrhosis both, so it is important to restrict sodium intake by reducing dietary salt intake. [1] [2] [3]
References
  1. BANSAL S., LINDENFELD J., SCHRIER R. W.. Sodium Retention in Heart Failure and Cirrhosis: Potential Role of Natriuretic Doses of Mineralocorticoid Antagonist?. Circulation: Heart Failure [online] December, 2(4):370-376 [viewed 17 August 2014] Available from: doi:10.1161/​CIRCHEARTFAILURE.108.821199
  2. FOUAD YM, YEHIA R. Hepato-cardiac disorders World J Hepatol [online] 2014 Jan 27, 6(1):41-54 [viewed 17 August 2014] Available from: doi:10.4254/wjh.v6.i1.41
  3. BAYRAKTAR U.D., SEREN S, BAYRAKTAR Y. Hepatic venous outflow obstruction: Three similar syndromes. World J Gastroenterol [online] 2007 April 7;13(13): 1912-1927 [viewed 16 August 2014] Available from: http://www.wjgnet.com/1007-9327/13/1912.asp