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Cardio-Hepatic Syndrome

Dr, Ayub Abdulkadir, MD at sureya clinic, and medical lecturer.<br> Definition of card hepatic syndrome, etiology, and how to be managed.

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Cardio-Hepatic Syndrome

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  1. Dr. Alto Medical Education Dr. Ayub Abdulkadir Abdi (Dr. ALTO) • Medical Doctor • Medical Lecturer • Ms Tropical Medicine & Infectious Disease • Bachelor of Medicine and Surgery • Medical Laboratory Technician Cardio-Hepatic Syndrome

  2. Definition: • The combination of clinical-laboratory signs of liver dysfunction and acute or chronic cardiac pathology. • Or • Liver injury in decompensated heart failure. Cardio-Hepatic Syndrome (Dr. Alto)

  3. Cardio-Hepatic Syndrome (Dr. Alto)

  4. Etiology: Cardio-Hepatic Syndrome (Dr. Alto)

  5. Pathogenesis: 1. Hypoperfusion-inducedhypoxia,and Hepatic ischemia characterized by: • Early activation of Kupffercells. • Late activation of: • Polymorphonuclearcells (“neutrophilic hepatitis”). • Intracellular calcium overload. • Cytokines andchemokines. • Oxidative stress, mitochondrial damage, and disruption of liver microcirculation. • CENTRILOBULAR COAGULATIVE NECROSIS. Cardio-Hepatic Syndrome (Dr. Alto)

  6. Cardio-Hepatic Syndrome (Dr. Alto)

  7. Acute Cardiogenic Injury: Cardio-Hepatic Syndrome (Dr. Alto)

  8. 2. Hepatic congestion due to absence of valves in hepatic veins leads to: • Increased inferior cavalpressure. • Centrilobularcongestion, sinusoidal dilation, and perivenularfibrosis. • Centrilobular liver cell necrosis. • Accumulation, deposition and spread of connective tissue. • Ultimately leading to CIRRHOSIS. Cardio-Hepatic Syndrome (Dr. Alto)

  9. Chronic Congestive Hepatopathy: Cardio-Hepatic Syndrome (Dr. Alto)

  10. Morphology: Cardio-Hepatic Syndrome (Dr. Alto)

  11. Cardio-Hepatic Syndrome (Dr. Alto)

  12. Cardio-Hepatic Syndrome (Dr. Alto)

  13. Criteria: • Setting: cardiac, circulatory, or pulmonary failure. • Aminotransferase levels, usually >20 times the upper limit of normal. • Exclusionof other causes of liver damage. Cardio-Hepatic Syndrome (Dr. Alto)

  14. Clinical Feature: • Hepatomegaly “ enlarged liver size” and it’s consequences including: • Pain in right hypochondrium. • Fatigue. • Nausea or lack of appetite. • Jaundice (yellowing of the skin and eyes). • Dark-colored urine and light-colored stools. • Itchy skin (pruritis). • Enlarged spleen (splenomegaly). • Ascites. • No development of variceal hemorrhage or encephalopathy. Cardio-Hepatic Syndrome (Dr. Alto)

  15. Cardio-Hepatic Syndrome (Dr. Alto)

  16. Other clinical feature: • CNS: headache, insomnia, restlessness, confusion. • Pulmonary: pulmonary hypertension, pleural effusion, cough, and dyspnea. • Cardiovascular: tachypnea. • Renal: oliguria, and nocturia. • Peripheral edema. Cardio-Hepatic Syndrome (Dr. Alto)

  17. Cardio-Hepatic Syndrome (Dr. Alto)

  18. Cardio-Hepatic Syndrome (Dr. Alto)

  19. Diagnosis: • Physical examination: • Firm liver on physical examination. Cardio-Hepatic Syndrome (Dr. Alto)

  20. Cardio-Hepatic Syndrome (Dr. Alto)

  21. Cardio-Hepatic Syndrome (Dr. Alto)

  22. Cardio-Hepatic Syndrome (Dr. Alto)

  23. 2- Lab test: • Elevated alkaline phosphate (normal level = 44 and 147 U/L). • Increased aminotransferase (AST > ALT). Normal level of AST = 8 to 33 U/L and ALT = 4 to 36 U/L • Elevated total bilirubin levels (normal level = 1 mg/dl). • Hypoalbuminemia (normal level = 3.4 to 5.4 g/dL). Cardio-Hepatic Syndrome (Dr. Alto)

  24. 3- Histopathology: • Liver biopsy shows a pattern of fibrosis. Cardio-Hepatic Syndrome (Dr. Alto)

  25. 4- Medical imaging: • Ultrasound: dilated IVC and dilated hepatic veins. Cardio-Hepatic Syndrome (Dr. Alto)

  26. Doppler ultrasound: Hepatic vein Doppler finding includes highly pulsatile blood flow showing a prominent d wave, a retrograde s and a wave Cardio-Hepatic Syndrome (Dr. Alto)

  27. Portal (A) and hepatic (B) vein waveforms at the time of cardiac decompensation. Note the pulsatile portal vein and monophasic [D is the only anterograde wave] hepatic vein tracings Cardio-Hepatic Syndrome (Dr. Alto)

  28. Portal (A) and hepatic (B) vein waveforms after decongestive therapy. Note improved pulsatility of the portal vein and return of the S-wave below the baseline on the hepatic vein tracing Cardio-Hepatic Syndrome (Dr. Alto)

  29. Pleural effusion: Cardio-Hepatic Syndrome (Dr. Alto)

  30. Pulmonary edema: Cardio-Hepatic Syndrome (Dr. Alto)

  31. Cardiomegaly Cardio-Hepatic Syndrome (Dr. Alto)

  32. Treatment: • Based on management of the underlying cardiac disease. • General measuremntssuch as: • Bed rest. • Stop smoking. • Low diet sodium intake. Cardio-Hepatic Syndrome (Dr. Alto)

  33. Drugs such as: • Diureteics. • Antihypertensive drugs. • Vasodilators. • Digitalis. • Anticoagulant. Cardio-Hepatic Syndrome (Dr. Alto)

  34. Surgery: • Coronary revascularization. • Bivantricular pacing. • Implantable cardioverterdefabrilization. • Left ventricular assist device. • Heart transplantation. Cardio-Hepatic Syndrome (Dr. Alto)

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