Nekkanti Ankita, Gopakumar Harishankar, Zainab Kaneez, Lynch Teresa, Dhillon Sonu
Department of Gastroenterology, University of Illinois College of Medicine at Peoria, USA.
Department of Internal Medicine, Medical University of South Carolina, USA.
J Community Hosp Intern Med Perspect. 2025 Jul 3;15(4):46-49. doi: 10.55729/2000-9666.1452. eCollection 2025.
Liver cirrhosis is commonly diagnosed with etiologies such as viral hepatitis, alcohol-related liver disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). However, less common causes should be considered, especially in atypical presentations or suboptimal treatment responses. A 67-year-old man presented with massive bilateral pedal edema unresponsive to furosemide. He had well-controlled diabetes and hypertension but no history of alcohol use. Laboratory tests showed normal renal function, mild transaminitis, and mild thrombocytopenia. Imaging revealed liver morphology suggestive of cirrhosis, which prompted the presumptive diagnosis of metabolic-associated steatohepatitis (MASH). Despite diuretic therapy, the patient's edema worsened, necessitating repeated hospital admissions for intravenous diuresis. Measurement of transhepatic pressures showed findings consistent with portal hypertension, but the degree of edema was disproportionate to the hepatic venous pressure gradient. Liver biopsy showed sinusoidal congestion suggesting cardiac causes of portal hypertension. Subsequent cardiac evaluation, including left and right heart catheterization and cardiac MRI, revealed constrictive pericarditis. The patient then underwent pericardiectomy, leading to substantial improvement in symptoms allowing cessation of diuretic therapy. The overlap of symptoms between cardiopulmonary and hepatic diseases can complicate diagnosis. Cardiac cirrhosis, though often asymptomatic, should be considered in patients with unexplained peripheral edema. Diagnostic challenges include normal echocardiograms and the need for advanced imaging. Careful evaluation and consideration of atypical presentations are crucial, with gastroenterologists playing a vital role in identifying cardiac conditions masquerading as primary liver disease.
肝硬化通常根据诸如病毒性肝炎、酒精性肝病和代谢功能障碍相关脂肪性肝病（MASLD）等病因进行诊断。然而，应考虑不太常见的病因，尤其是在非典型表现或治疗反应欠佳的情况下。一名67岁男性出现双侧严重足部水肿，对呋塞米无反应。他的糖尿病和高血压得到良好控制，但无饮酒史。实验室检查显示肾功能正常、轻度转氨酶升高和轻度血小板减少。影像学检查显示肝脏形态提示肝硬化，这促使初步诊断为代谢相关脂肪性肝炎（MASH）。尽管进行了利尿治疗，但患者的水肿仍加重，需要反复住院进行静脉利尿。经肝压力测量结果与门静脉高压一致，但水肿程度与肝静脉压力梯度不成比例。肝活检显示窦性充血，提示门静脉高压的心脏病因。随后的心脏评估，包括左右心导管检查和心脏MRI，显示为缩窄性心包炎。患者随后接受了心包切除术，症状得到显著改善，从而可以停止利尿治疗。心肺疾病和肝脏疾病症状的重叠会使诊断复杂化。心脏性肝硬化虽然通常无症状，但对于不明原因外周水肿的患者应予以考虑。诊断挑战包括超声心动图正常以及需要先进的影像学检查。仔细评估和考虑非典型表现至关重要，胃肠病学家在识别伪装成原发性肝病的心脏疾病方面发挥着至关重要的作用。
