Introduction
The heart and liver are the two most important organs of the human body. Both of these organs play a vital role in maintaining the integrity of blood circulation. Thus, liver problems may lead to heart issues and vice-versa. Congestive hepatopathy is a similar heart disease, a liver disorder caused by heart problems.
What Is Congestive Heapatopathy?
Congestive hepatopathy is a spectrum of conditions characterized by congestion of hepatic flow. This congestion is caused by the rise of hepatic venous flow. The congestion of hepatic flow occurs because of multiple reasons these are:
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Congestive Pericarditis: In this condition, granulation tissues are formed around the layer of the heart. As a result, the elasticity of the cardiac tissue is lost. This causes a decrease in the cardiac output and stroke output of the heart.
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Tricuspid Valve Regurgitation: In this condition, the flaps of the tricuspid valves do not work correctly. The tricuspid valve is placed between the right atrium and the right ventricular. In this condition, this valve does not close properly.
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Mitral Stenosis: Mitral valve is present in between the left ventricle and left atrium. Dysfunction of this valve is caused by conditions like calcification, rheumatic fever, and endocarditis. This causes elevated pressure on the left atrium. This elevated pressure is transmitted to the pulmonary blood vessels and is responsible for increased pressure in the pulmonary circulation.
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Cor Pulmonale: This is a condition responsible for structural and functional changes in the right side of the heart. Increased pressure on the pulmonary circulation is associated with this condition. Several conditions like chronic obstructive pulmonary disorder, cystic fibrosis, and the presence of blood clots in the lungs are associated with a rise of pressure in the pulmonary circulation. This increases the extra workload on the right side of the heart and is responsible for right-sided failure of the heart.
Apart from this, conditions like the Fontan procedure (a corrective procedure done in person with only one working ventricle) and Ebstein anomaly (congenital heart defect with wrong positing of the tricuspid valve) are responsible for congestive hepatopathy.
What Are the Symptoms of Congestive Hepatopathy?
Congestive hepatopathy remains symptomless at the beginning. Usual symptoms of right-sided heart failure like difficulty in breathing, breathing difficulty after exercise, and heaviness in the chest. Subsequently, the patient develops symptoms like swelling of the abdomen, prominence of the blood capillaries in the abdomen, accumulation of excessive fluid in the abdomen, and swelling of the body parts like legs, ankle, and hand.
What Is the Pathophysiology of Congestive Hepatopathy?
The liver is one of the largest organs in the human body. It is reached in the blood supply. It receives blood supply from both the hepatic artery and portal circulation. It receives almost 25 percent of cardiac output. As the cardiac output decreases, the blood flow to the liver decreases. The vascular mechanism of the liver is designed in such a way that it can regulate the blood flow in various conditions like ischemia (less oxygen supply to the organ). As a result of it, the hepatic venous pressure increases, and oxygen saturation in the arteries is decreased. The elevated pressure in the hepatic veins obstructs the inflow of the portal vein circulation. The damage mechanism of the liver is done through the following ways:
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Alliteration in the blood supply produces stress. This causes increased production of collagen and fibrous tissues. Activation of the hepatic stellate cells due to sinusoidal ischemia also plays a vital role in this process. A decreased production of nitric oxide from endothelial cells. Sinusoidal (a type of tiny blood vessel) ischemia is mainly caused by sinusoidal congestion, dilation of sinusoidal fenestrae, and accumulation of protein and fluid into the space of Disse (space between hepatic cells and sinusoids).
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Impairment of the diffusion of nutrients is also responsible for increased fibrosis.
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Stimulation in the protease-activated receptors leads to the activation of hepatic stellate cells. Circulatory stasis is associated with thrombus formation, which is associated with the activation of these cells. This mechanism is also responsible for fibrosis of liver tissues.
What Are the Imaging Features of Congestive Hepatopathy?
Several imaging modalities can be used for the diagnosis of congestive hepatopathy. These features are:
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Radiological Evaluation: Radiological features are not pronounced and specific in the diagnosis of congestive hepatopathy. Features like hepatomegaly (enlargement of the liver) can be observed. Calcification around the heart, enlargement of the right side of the heart, and formation of granulation tissue around the pericardium (the covering of the heart) can be seen.
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Ultrasound Evaluation: Ultrasound evaluation is one of the key methods in the evaluation of the hemodynamic properties of the liver. The direction of the blood flow and its velocity is determined by the Color Doppler ultrasound evaluation. Dilation of the right hepatic vein can be observed. Dilatation of the inferior vena cava and poor venous flow can be seen.
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Computed-Tomography Imaging: Enlargement of the liver with the presence of atrophic nodules and venous congestion can be observed. Atrophic and nodular changes occur at a later stage, with changes similar to cirrhosis can be visible. Increased density of the abdomen is also seen. Well-circumscribed, homogeneous, and nodular appearance produces a washout appearance that is similar to hepatocarcinoma.
What Are the Other Diagnostic Test?
The other diagnostic tests for congestive hepatopathy are:
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The serum bilirubin level is mildly elevated. The elevation of the unconjugated bilirubin is mainly seen.
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The elevated levels of alkaline phosphatase and gamma-glutamyl transferase can detect reduced bile flow.
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Reduction in the albumin level and elevation in the levels of aminotransferases can also be observed.
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The level of aspartate aminotransferase (AST) is also elevated.
What Are the Treatment Options?
The primary treatment option for congestive hepatopathy is to treat underlying cardiac complications. Diuretics can be used to minimize hepatic congestion. However, these drugs may increase hepatic ischemia. In severe cases left ventricular assist device (LVAD) or cardiac transplantation can be planned. In certain cases, a combination of heart-liver transplantation can also be done.
Conclusion
The liver is an important organ that is rich in blood supply. Right-sided heart failure causes the circulatory status of the hepatic blood vessels. This causes ischaemic changes in the liver tissues. As a result, liver fibrosis occurs. This causes structural and functional damage to the liver. This condition is known as congestive hepatopathy.
