History

Fact Explanation
Asymptomatic Some patients with hepatic infarction remain asymptomatic. [3]
Abdominal pain [2] Patients present with pain in the right hypochondrium due to renal ischemia.
Jaundice Some patients can present with jaundice due to liver failure.
History of transjugular intrahepatic portosystemic shunt (TIPS) placement Patients with cirrhosis can develop hepatic infarction after placement of a TIPS. [3]
History of liver biopsy Development of hepatic artery pseudoaneurysms (HAP) is a complication of liver biopsy. Patients with HAP can be asymptomatic or present with abdominal pain, hematemesis, anemia, hypovolemia, massive gastrointestinal bleeding and jaundice after the liver biopsy. [2]
Treatment of hepatocellular carcinoma (HCC) Among the options of treatment for HCC percutaneous ethanol injection and percutaneous arterial embolization carries a risk of hepatic infarction. Although rare, RFA also carries a small risk of hepatic infarction. [1]
History of laparoscopic abdominal surgery Patients who have underwent laparoscopic abdominal surgery, can develop hepatic necrosis as a complication of the procedure. Anesthetic agents, accidental ligation or cutting of the vessels can be the causative factors. [4]
History of pre-eclampsia Pre-eclampsia is a complication of pregnancy induced hypertension (PIH). PIH occurs in the second trimester of the pregnancy. Females present with high blood pressure, generalized edema and in severe cases seizures can develop. [5]
History of antiphospholipid syndrome (APS) Patients with APS are at risk of hepatic infarction due to thrombosis of vessels. [6]
References
  1. LADRA GONZáLEZ MARíA JESúS, ECHEVARRíA CANOURA MARíA, FERNáNDEZ CASTROAGUDíN JAVIER, BUSTAMANTE MONTALVO MANUEL. A Massive Hepatic Infarction After Radiofrequency Ablation. Cirugía Española (English Edition) [online] 2013 February, 91(2):122-124 [viewed 17 August 2014] Available from: doi:10.1016/j.cireng.2011.10.006
  2. BISHEHSARI F, TING PS, GREEN RM. Recurrent gastrointestinal bleeding and hepatic infarction after liver biopsy. World J Gastroenterol [online] 2014 Feb 21, 20(7):1878-81 [viewed 17 August 2014] Available from: doi:10.3748/wjg.v20.i7.1878
  3. LóPEZ-MéNDEZ E, ZAMORA-VALDéS D, DíAZ-ZAMUDIO M, FERNáNDEZ-DíAZ OF, ÁVILA L. Liver failure after an uncovered TIPS procedure associated with hepatic infarction World J Hepatol [online] 2010 Apr 27, 2(4):167-170 [viewed 17 August 2014] Available from: doi:10.4254/wjh.v2.i4.167
  4. TAMHANKAR AP, KELTY CJ, JACOB G. Retraction-Related Liver Lobe Necrosis After Laparoscopic Gastric Surgery JSLS [online] 2011, 15(1):117-121 [viewed 17 August 2014] Available from: doi:10.4293/108680811X13022985131651
  5. POWE C. E., LEVINE R. J., KARUMANCHI S. A.. Preeclampsia, a Disease of the Maternal Endothelium: The Role of Antiangiogenic Factors and Implications for Later Cardiovascular Disease. Circulation [online] December, 123(24):2856-2869 [viewed 17 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.109.853127
  6. UTHMAN I., KHAMASHTA M.. The abdominal manifestations of the antiphospholipid syndrome. Rheumatology [online] 2007 November, 46(11):1641-1647 [viewed 17 August 2014] Available from: doi:10.1093/rheumatology/kem158

Examination

Fact Explanation
Jaundice Patients can develop jaundice with liver failure. [1]
Edema Generalized pitting edema is another manifestation of severe liver failure.
References
  1. LóPEZ-MéNDEZ E, ZAMORA-VALDéS D, DíAZ-ZAMUDIO M, FERNáNDEZ-DíAZ OF, ÁVILA L. Liver failure after an uncovered TIPS procedure associated with hepatic infarction World J Hepatol [online] 2010 Apr 27, 2(4):167-170 [viewed 17 August 2014] Available from: doi:10.4254/wjh.v2.i4.167

Differential Diagnoses

Fact Explanation
Budd–Chiari syndrome Thrombosis of the hepatic vein results in Budd–Chiari syndrome. Venous congestion of the liver results in acute liver failure. Abdominal pain, hepatomegaly, ascites and jaundice can be seen in most of the patients. Fulminant liver failure can result in hepatic encephalopathy. [1]
Acute hepatitis Acute hepatitis A, B, C, D and E infections can present with jaundice. Elevated hepatic transaminases, elevated bilirubin and prolonged PT/INR can be observed in liver profile. [2]
Alcoholic liver disease Patients with a history of alcohol abuse are at risk of developing alcoholic hepatitis. Elevated hepatic transaminases, gamma glutamyl transferase and bilirubin, prolonged prothrombin time and hypoalbuminemia can be detected. [3]
Acetaminophen overdose Acetaminophen overdose is a cause for acute liver failure. Patients can be asymptomatic or can present with nausea, vomiting and right hypochondrial pain. [4]
Autoimmune hepatitis Autoimmune hepatitis is common in females. Diagnosis is often favored by exclusion of other possible etiologies and by demonstrating the presence of auto-antibodies. [5] The definitive diagnosis is made according to the diagnostic criteria of the International Autoimmune Hepatitis Group. [6]
Carcinoma of the head of the pancrease This is a cause of painless obstructive jaundice. Patients present with dark urine and pale stools in addition to jaundice. Newly diagnosed diabetes can also be present in some patients. [7]
References
  1. MENON K.V. NARAYANAN, SHAH VIJAY, KAMATH PATRICK S.. The Budd–Chiari Syndrome. N Engl J Med [online] 2004 February, 350(6):578-585 [viewed 17 August 2014] Available from: doi:10.1056/NEJMra020282
  2. RYDER S D. ABC of diseases of liver, pancreas, and biliary system: Acute hepatitis. [online] 2001 January, 322(7279):151-153 [viewed 17 August 2014] Available from: doi:10.1136/bmj.322.7279.151
  3. BRUHA R, DVORAK K, PETRTYL J. Alcoholic liver disease World J Hepatol [online] 2012 Mar 27, 4(3):81-90 [viewed 17 August 2014] Available from: doi:10.4254/wjh.v4.i3.81
  4. Paracetamol (acetaminophen) poisoning : No need to change current guidelines to accident departments BMJ [online] 1998 Dec 12, 317(7173):1609-1610 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1114433
  5. CZAJA AJ, FREESE DK, AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASE. Diagnosis and treatment of autoimmune hepatitis. Hepatology [online] 2002 Aug, 36(2):479-97 [viewed 17 August 2014] Available from: doi:10.1053/jhep.2002.34944
  6. ALVAREZ F, BERG PA, BIANCHI FB, BIANCHI L, BURROUGHS AK, CANCADO EL, CHAPMAN RW, COOKSLEY WG, CZAJA AJ, DESMET VJ, DONALDSON PT, EDDLESTON AL, FAINBOIM L, HEATHCOTE J, HOMBERG JC, HOOFNAGLE JH, KAKUMU S, KRAWITT EL, MACKAY IR, MACSWEEN RN, MADDREY WC, MANNS MP, MCFARLANE IG, MEYER ZUM BüSCHENFELDE KH, ZENIYA M. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol [online] 1999 Nov, 31(5):929-38 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10580593
  7. CASCINU S., JELIC S.. Pancreatic cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 20(Supplement 4):iv37-iv40 [viewed 17 August 2014] Available from: doi:10.1093/annonc/mdp123

Investigations - for Diagnosis

Fact Explanation
Hepatic transaminases Death of hepatocytes causes elevated transaminases. [1,3]
Liver function test Hepatic infarction results in liver failure. Elevated bilirubin and prolonged PT/INR can be observed. [2]
Ultrasound scan Ultrasound scan of the liver shows areas of decreased echogenicity. When combined with Doppler scans ultrasound scan is helpful in in detecting obliterated vessel. [4,5]
CT scan CT scan shows the wedge-shaped, rounded or irregular lesions of hepatic infarction as hypodense areas. In the presence of secondary infection gas can be seen around the area of infarction. [2,3]
Angiogram [2] Angiogram can localize the obliterated vessel which is responsible for the development of hepatic infarction.
Nuclear imaging [2] Ischemic and necrosed areas of the liver paranchyma can be illustrated with the use of nuclear imaging.
References
  1. BISHEHSARI F, TING PS, GREEN RM. Recurrent gastrointestinal bleeding and hepatic infarction after liver biopsy. World J Gastroenterol [online] 2014 Feb 21, 20(7):1878-81 [viewed 17 August 2014] Available from: doi:10.3748/wjg.v20.i7.1878
  2. LóPEZ-MéNDEZ E, ZAMORA-VALDéS D, DíAZ-ZAMUDIO M, FERNáNDEZ-DíAZ OF, ÁVILA L. Liver failure after an uncovered TIPS procedure associated with hepatic infarction World J Hepatol [online] 2010 Apr 27, 2(4):167-170 [viewed 17 August 2014] Available from: doi:10.4254/wjh.v2.i4.167
  3. TAMHANKAR AP, KELTY CJ, JACOB G. Retraction-Related Liver Lobe Necrosis After Laparoscopic Gastric Surgery JSLS [online] 2011, 15(1):117-121 [viewed 17 August 2014] Available from: doi:10.4293/108680811X13022985131651
  4. COOK G J, CROFTON M E. Hepatic artery thrombosis and infarction: evolution of the ultrasound appearances in liver transplant recipients.. The British Journal of Radiology [online] 1997 March, 70(831):248-251 [viewed 17 August 2014] Available from: doi:10.1259/bjr.70.831.9166048
  5. SEGEL MC, ZAJKO AB, BOWEN A, SKOLNICK ML, BRON KM, PENKROT RJ, SLASKY BS, STARZL TE. DOPPLER ULTRASOUND AS A SCREEN FOR HEPATIC ARTERY THROMBOSIS AFTER LIVER TRANSPLANTATION Transplantation [online] 1986 Apr, 41(4):539-541 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221454

Investigations - Fitness for Management

Fact Explanation
Renal function test Renal failure can arise as a complication of liver failure (hepato-renal syndrome). Patients have elevated serum creatinine and abnormal electrolyte profile. [1]
References
  1. NG CK, CHAN MH, TAI MH, LAM CW. Hepatorenal Syndrome Clin Biochem Rev [online] 2007 Feb, 28(1):11-17 [viewed 17 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904420

Investigations - Followup

Fact Explanation
Liver function test Progression of the disease and recovery should be monitored with liver function tests (serum bilirubin, PT/INR) and hepatic transaminases. [1]
References
  1. LóPEZ-MéNDEZ E, ZAMORA-VALDéS D, DíAZ-ZAMUDIO M, FERNáNDEZ-DíAZ OF, ÁVILA L. Liver failure after an uncovered TIPS procedure associated with hepatic infarction World J Hepatol [online] 2010 Apr 27, 2(4):167-170 [viewed 17 August 2014] Available from: doi:10.4254/wjh.v2.i4.167

Management - General Measures

Fact Explanation
Management of bile leakage If bile leaking is present, it can be treated with either percutaneous drainage or with surgery. [1]
Management of hepatic abscess Some patients with hepatic infarction can develop secondary infection and abscess formation. Percutaneous drainage of the abscess can be done. Open surgical drainage should be done if percutaneous drainage fails. [1]
References
  1. TAMHANKAR AP, KELTY CJ, JACOB G. Retraction-Related Liver Lobe Necrosis After Laparoscopic Gastric Surgery JSLS [online] 2011, 15(1):117-121 [viewed 17 August 2014] Available from: doi:10.4293/108680811X13022985131651

Management - Specific Treatments

Fact Explanation
Conservative management Most of the uncomplicated hepatic infarctions can be managed conservatively. [2]
Surgery Surgical resection of the necrosed liver paranchyma is indicated if conservative management fails or if the patient develops complications (bile leakage, abscess formation). [2]
Management of hepatic artery pseudoaneurysm Hepatic artery pseudoaneurysm is treated with endovascular embolization or open surgical repair. [1]
References
  1. BISHEHSARI F, TING PS, GREEN RM. Recurrent gastrointestinal bleeding and hepatic infarction after liver biopsy. World J Gastroenterol [online] 2014 Feb 21, 20(7):1878-81 [viewed 17 August 2014] Available from: doi:10.3748/wjg.v20.i7.1878
  2. TAMHANKAR AP, KELTY CJ, JACOB G. Retraction-Related Liver Lobe Necrosis After Laparoscopic Gastric Surgery JSLS [online] 2011, 15(1):117-121 [viewed 17 August 2014] Available from: doi:10.4293/108680811X13022985131651