(See also Overview of Vascular Disorders of the Liver Overview of Vascular Disorders of the Liver The liver has a dual blood supply. The portal vein (which is rich in nutrients and relatively high in oxygen) provides two thirds of blood flow to the liver. The hepatic artery (which is oxygen-rich)... read more .)
Etiology of Ischemic Hepatitis
Causes are most often systemic:
Impaired hepatic perfusion (eg, due to heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more
or acute hypotension)Hypoxemia (eg, due to respiratory failure Overview of Respiratory Failure Acute respiratory failure is a life-threatening impairment of oxygenation, carbon dioxide elimination, or both. Respiratory failure may occur because of impaired gas exchange, decreased ventilation... read more or carbon monoxide toxicity Carbon Monoxide Poisoning Carbon monoxide (CO) poisoning causes acute symptoms such as headache, nausea, weakness, angina, dyspnea, loss of consciousness, seizures, and coma. Neuropsychiatric symptoms may develop weeks... read more )
Focal lesions of the hepatic vasculature are less common causes. Ischemic hepatitis may develop when hepatic artery thrombosis occurs during liver transplantation Liver Transplantation Liver transplantation is the 2nd most common type of solid organ transplantation. (See also Overview of Transplantation.) Indications for liver transplantation include Cirrhosis (70% of transplantations... read more or when thrombosis of the portal vein Portal Vein Thrombosis Portal vein thrombosis causes portal hypertension and consequent gastrointestinal bleeding from varices, usually in the lower esophagus or stomach. Diagnosis is based on ultrasonography. Treatment... read more and hepatic artery develops in a patient with sickle cell crisis Sickle Cell Disease Sickle cell disease (a hemoglobinopathy) causes a chronic hemolytic anemia occurring almost exclusively in people with African ancestry. It is caused by homozygous inheritance of genes for hemoglobin... read more 
(thus compromising the dual blood supply to the liver). Centrizonal necrosis develops without liver inflammation (ie, not true hepatitis).
Symptoms and Signs of Ischemic Hepatitis
Symptoms may include nausea, vomiting, and tender hepatomegaly.
Diagnosis of Ischemic Hepatitis
Clinical evaluation and liver tests
Doppler ultrasonography, MRI, or arteriography
Ischemic hepatitis is suspected in patients who have risk factors and laboratory abnormalities:
Serum aminotransferase increases dramatically (eg, to 1000 to 3000 IU/L).
Lactic dehydrogenase (LDH) increases within hours of ischemia (unlike acute viral hepatitis).
Serum bilirubin increases modestly, only to ≤ 4 times its normal level.
Prothrombin time/international normalized ratio (PT/INR) increases.
Diagnostic imaging Imaging Tests of the Liver and Gallbladder Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more 
helps define the cause: Doppler ultrasonography, MRI, or arteriography can identify an obstructed hepatic artery or portal vein thrombosis Portal Vein Thrombosis Portal vein thrombosis causes portal hypertension and consequent gastrointestinal bleeding from varices, usually in the lower esophagus or stomach. Diagnosis is based on ultrasonography. Treatment... read more .
Treatment of Ischemic Hepatitis
Hepatic reperfusion
Treatment is directed at the cause, aiming to restore hepatic perfusion, particularly by improving cardiac output and reversing any hemodynamic instability.
If perfusion is restored, aminotransferase decreases over 1 to 2 weeks. In most cases, liver function is fully restored. Fulminant liver failure Acute Liver Failure Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. Treatment is mainly supportive... read more , although uncommon, can occur in patients with preexisting cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture. Cirrhosis is characterized by regenerative nodules surrounded by dense... read more .
