November 27, 2009

Congestive Hepatomegaly , Ischemic Cholangiopathy

Congestive Hepatomegaly
Congestive hepatomegaly is a backup of blood in the liver, resulting from heart failure.

Severe heart failure causes blood to back up from the heart into the inferior vena cava (the large vein that carries blood from the lower parts of the body to the heart). Such congestion increases pressure in this vein and other veins that carry blood to it, including the hepatic veins (which drain blood from the liver). If this pressure is high enough, the liver becomes engorged (congested) with blood and malfunctions.

In most people, the congested liver causes only mild abdominal discomfort. The liver (in the upper right part of the abdomen) is tender and enlarged. In severe cases, the skin and whites of the eyes may turn yellow—a disorder called jaundice. Fluid may accumulate in the abdomen—a disorder called ascites. The spleen also tends to enlarge. If congestion is severe and chronic, liver damage or even severe scarring (cirrhosis) develops.

Doctors suspect the disorder in people with heart failure who have typical symptoms and abnormal results on blood tests done to evaluate the liver.

Management focuses on treating the heart failure. Such treatment may restore normal liver function.
Ischemic Cholangiopathy
Ischemic cholangiopathy is damage to one or more bile ducts caused by inadequate blood flow.

Bile ducts (such as the hepatic ducts and the common bile duct), unlike the liver, are supplied with blood from only one major blood vessel, the hepatic artery. Thus, disruption of blood flow through the hepatic artery can prevent the bile ducts from obtaining enough oxygen. Consequently, the cells lining the ducts are damaged or die—a disorder called ischemic cholangiopathy. Blood flow can be disrupted by the following:

  • Surgical trauma during liver transplantation or removal of the gallbladder by laparoscopy
  • Injury from radiation therapy
  • A disorder that makes blood more likely to clot (blood clotting disorder)
  • A procedure to block a bleeding blood vessel that causes clot formation (embolization)

Ischemic cholangiopathy is mostly commonly seen in those who have had a liver transplant.

Symptoms and Diagnosis

The damaged bile duct narrows (causing a stricture) so that the flow of bile slows or is blocked. As a result, bile pigment (bilirubin) is retained, the skin and the whites of the eyes turn yellow (called jaundice) and the urine becomes dark. As bile (containing pigment such as bilirubin) does not enter the small intestine, the stools become pale. Itching (termed pruritus) is common, often beginning in the hands and feet but usually affecting the whole body. Itching is especially worse at night. Bile duct infection (cholangitis) may also occur, producing abdominal pain, chills and fever.

The diagnosis comes from the symptoms and abnormal blood test results, especially in people who have conditions that make ischemic cholangiopathy more likely (eg, liver transplant recipients). Ultrasonography helps doctors visualize the ducts, but the results may be inconclusive. Better definition often requires magnetic resonance imaging of the bile ducts (a procedure called magnetic resonance cholangiopancreatography or MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). ERCP involves inserting a flexible viewing tube (endoscope) through the mouth and into the small intestine and injecting dye into the bile duct system.


In addition to detecting the narrowing of the bile ducts, ERCP can be used in treatment. A wire with a deflated balloon at its end is introduced through the endoscope; doctors inflate the balloon to widen (dilate) the narrowing. A mesh tube (stent) then keeps the duct open.

People who have had a liver transplant on occasion may require another transplant.
Adapted from: Merck & Co., Inc.