Case Presentation: An 81 year old female with chronic kidney disease, severe tricuspid regurgitation and a pacemaker presented after a fall with a completely displaced left femoral neck fracture. She underwent a left hip hemiarthroplasty without initial complication. On post operative day 2, the patient developed altered mental status and was noted to have anasarca and asterixis with an ammonia level at 68. A previous hospitalization was noted for presumed hepatic encephalopathy, yet work up for known causes of cirrohisis was negative, as was two abdominal ultrasounds for any evidence of cirrotic changes. Despite this inconclusive workup from one month prior the patient was now started on lactulose and rifaxamin for presumed hepatic encephalopathy. A repeat ultrasound of the abdomen with doppler now demonstrated a nodular liver consistent with cirrhosis and portal hypertension. Other causes of cirrhosis were ruled out and a diagnosis of cirrhosis secondary to congestive hepatopathy caused by severe tricuspid regurgitation and right sided heart failure was made. Cardiothoracic surgery was consulted for tricuspid valve replacement but unfortunately, the patient was deemed too high of a risk due to her multiple comorbidities and her high MELD score. The patient was medically optimized and discharged to a subacute rehabilitation facility.
Discussion: Cirrhosis is a common disease entity, representing fibrosis arising from excess accumulation of extracellular matrix due to chronic liver inflammation. While the most common causes of cirrhosis include viral hepatitis, alcoholic liver disease and nonalcoholic fatty liver disease, ten percent of cases are cryptogenic. Cardiac cirrhosis is an often overlooked rare cause of cryptogenic cirrhosis. Cardiac cirrhosis develops as right sided heart failure (caused by tricuspid regurgitation in this patient) increases hepatic venous pressures leading to ischemia and finally fibrosis. While a definitive diagnosis of cirrhosis is made histologically from a liver biopsy, non-invasive imaging including ultrasound, CT and MRI are commonly used to diagnose cirrhosis. Although abdominal ultrasound is a useful modality to identify liver disease, it often only identifies advanced cirrhosis. Ultrasound of the liver is limited by small acoustic windows and operator dependence, as evidenced by the false negative report in our patient. Once diagnosed, definitive treatment of cardiac cirrhosis focuses on treating the source of heart failure. Unfortunately, performing cardiac surgery in a patient with cirrhosis carries a mortality rate of approximately 26% with a greater incidence of post-operative comorbidities.
Conclusions: Right sided heart failure is an under-recognized cause of cirrhosis. In a patient with cryptogenic cirrhosis consider a cardiac source in your evaluation.
To cite this abstract:Honigman J, Weinstein J, Katona K. The Tale of the Regurgitant Liver. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 544. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/the-tale-of-the-regurgitant-liver/. Accessed March 30, 2020.