A Dangerous Trifecta for Transaminitis: Hepatic Congestion, , and COVID-19 Margaret A. Mallari, DO Sujai Jalaj, MD AtlantiCare Regional Medical Center Atlantic City, New Jersey

Introduction Results Discussion

• Due to its vasculature and high metabolic • The is a highly vascular organ, receiving 25% of requirements, the liver is prone to injury from the cardiac output, thus is quite prone to low flow diminished perfusion. states. • Congestive describes the symptoms • Patients with hepatic congestion may present with and manifestations secondary to passive hepatic , right upper quadrant pain, and . congestion, which can be seen in patients with • Patients with baseline passive hepatic congestion are right-sided . at increased risk for ischemic injury known as acute cardiogenic liver injury. Case • Our patient presented with the hallmark findings of ischemic : severe jaundice, a level as • A 37-year-old male with past medical history of high as 15 to 20 mg/dL, a AST more than 10 x the non-ischemic with AICD and upper limit, a significant increase in LDH, and elevated chronic amphetamine use presented to the alk phos level, and markedly prolonged PT. emergency department with that • Clinical symptoms of do not worsened with food intake. generally manifest until the development of . • Physical exam revealed jaundice with scleral Our patient demonstrated a positive hepatojugular icterus, tenderness to palpation of the right upper reflex, jaundice, ascites, and pitting peripheral . , and ascites. • The patient had chronic hepatic congestion secondary • CT of the A + P showed cholelithiasis, bilateral to his severe drug-induced cardiomyopathy. The pleural effusions, and cardiac enlargement. COVID-19 precipitated cardiogenic • Abdominal US showed cholelithiasis, resulting in worsening transaminitis and bilirubinemia. wall thickening, and Murphy’s sign. CT of the abdomen and pelvis showed • Treatment of depends upon correct • UDS was positive for amphetamines and cannabis, cholelithiasis significant and cardiac management of the underlying cardiac condition with a proBNP was greater than 4000, and SARS-COV-2 enlargement. focus on cardiac output optimization. PCR was positive. • The addition of diuretics can improve hepatic • He had significant bilirubinemia and transaminitis: References congestion but can also worsen existing hepatic total bilirubin 43.5 mg/dL (0.3-1.2), direct bilirubin ischemia. In severe hepatic congestion, improvement in 36 mg/dL (0-0.3), AST 7453 IU/L (15-40), ALT Russell SD, Rogers JG, Milano CA, Dyke DB, Pagani FD, Aranda JM, et al.; HeartMate II Clinical liver function has been observed after placement of a 4789 IU/L (4-47), LDH 317 U/L (111-233), Alk Investigators . Renal and hepatic function improve in left ventricular assist device (LVAD) or a cardiac Phos 272 U/L (45-117), PT 49.3 seconds (9.5 to advanced heart failure patients during continuous‐flow transplant. 12) and INR 5.5 (0.9-1.2). support with the HeartMate II left ventricular assist device. Circulation 2009;120:2352‐2357. Conclusion • ECHO showed severe enlargement of the left ventricular cavity, severe global hypokinesis of the Dichtl W, Vogel W, Dunst KM, Grander W, Alber HF, • The management of hepatic congestion and cardiac LV, severe pulmonary hypertension, and ejection Frick M, et al. Cardiac hepatopathy before and after cirrhosis centers around optimizing cardiac output and ‐ fraction (EF) 10%. heart transplantation. Transpl Int 2005;18:697 702. addressing the underlying cardiac condition. • Patient was deemed not a surgical candidate for Chokshi A, Cheema FH, Schaefle KJ, Jiang J, Collado • Cardiac cirrhosis rarely determines the patient’s clinical cholecystectomy due to severely low EF. E, Shahzad K, et al. Hepatic dysfunction and survival outcome. The underlying cardiac condition is the driver • Throughout the hospitalization, the patient after orthotopic heart transplantation: application of of significant morbidity and mortality. However, liver the MELD scoring system for outcome prediction. J continued to deteriorate, requiring vasopressor Heart Lung Transplant 2012;31:591‐600. function plays an important variable when considering support due to cardiogenic shock. surgical management of cardiac cirrhosis refractory to • HIDA scan showed no cystic duct obstruction. Gitlin N, Serio K M. Ischemic hepatitis: widening medical management. Studies have shown that • MRCP showed no evidence of biliary dilatation. horizons. Am J Gastroenterol. 1992;87(7):831–836. patients with higher Model for End-Stage • Transaminitis and bilirubinemia were determined to Cassidy W M, Reynolds T B. Serum lactic (MELD) scores have worse outcomes after and be secondary to shocked liver in the setting of dehydrogenase in the of acute decreased 10-year survival rates. acute hypotension and chronic hepatic congestion hepatocellular injury. J Clin Gastroenterol. • Though the patient has severe ischemic hepatitis, he is 1994;19(2):118–121. from severe congestive heart failure. not a candidate for a liver transplant. • Vitamin K was given to address coagulopathy, and Naschitz JE, Slobodin G, Lewis RJ, Zuckerman E, • Due to his severely low EF, the patient requires a heart the patient was placed on a milrinone drip to Yeshurun D. Heart diseases affecting the liver and transplant before a liver transplant. However, due to the liver diseases affecting the heart. Am Heart J maximize cardiac output. 2000;140:111‐120. patient’s ongoing use of illicit substances, he is not a • The patient's clinical status eventually improved, candidate for a heart transplant, and his long-term allowing downgrade from ICU. prognosis is very poor.