Cellarier G, Bonal J, Bouchiat C, Talard P, Dussarat G V
Service de Cardiologie, Hôpital d'Instruction des Armées Sainte-Anne, Toulon Naval.
Presse Med. 1995 Oct 21;24(31):1418-20.
Ischaemic hepatitis, a condition to be distinguished from cardiac liver or stasis cirrhosis, can occur as an acute episode in patients with advanced stage congestive heart failure. The mechanism is massive necrosis in the central lobules resulting from acute hypoxia when low cardiac output reduces oxygen supply further aggravating the underlying condition of congestion due to poor venous outflow. We report 4 cases which illustrate the difficulties in diagnosis and treatment. All four patients (age range 79-86 years) were seen in an emergency situation caused by an acute drop in cardiac output aggravating their underlying heart failure. Clinical signs included jaundice, oligouria, abdominal pain and cardiovascular shock. The first element suggesting the diagnosis of ischaemic hepatitis was a sudden and massive peak in transaminase levels (> 20 times normal) which rapidly returned to normal. Prothrombin and fibrinogen levels fell rapidly and functional renal failure was present in all cases. Viral serology was negative and no hepatotoxic drugs could be incriminated. Despite symptomatic intensive care one patient died on day 15 due to cardiovascular shock. Enzyme movements, together with the lack of evidence for another cause, is the key to diagnosis of acute ischaemic hepatitis which thus is often established after the emergency situation has been controlled. Initially, viral hepatitis or drug-induced hepatotoxicity may be suspected, especially if the episode of low cardiac output goes unrecognized. Cases with signs of encephalopathy may also be difficult to distinguish from fulminating hepatitis and would be the only indication for needle biopsy in this acute situation. Outcome is generally unfavourable with mortality at 6 months estimated at 50%.
缺血性肝炎是一种需与心性肝或淤血性肝硬化相鉴别的疾病，可发生于晚期充血性心力衰竭患者的急性发作期。其机制是当心输出量降低导致氧供应减少，进一步加重因静脉回流不畅引起的潜在淤血状态时，中央小叶发生大量坏死。我们报告4例病例以说明诊断和治疗中的困难。所有4例患者（年龄79 - 86岁）均因心输出量急性下降加重其潜在心力衰竭而处于紧急情况。临床体征包括黄疸、少尿、腹痛和心血管休克。提示缺血性肝炎诊断的首个因素是转氨酶水平突然大幅升高（>正常20倍），随后迅速恢复正常。凝血酶原和纤维蛋白原水平迅速下降，所有病例均存在功能性肾衰竭。病毒血清学检查为阴性，且无肝毒性药物可归咎。尽管进行了对症重症监护，1例患者在第15天因心血管休克死亡。酶学变化以及缺乏其他病因的证据是急性缺血性肝炎诊断的关键，因此该病常在紧急情况得到控制后才得以确诊。最初，可能怀疑为病毒性肝炎或药物性肝毒性，尤其是在心输出量降低的情况未被识别时。有肝性脑病体征的病例也可能难以与暴发性肝炎相鉴别，而这是这种急性情况下进行肝穿刺活检的唯一指征。总体预后不佳，估计6个月死亡率为50%。
