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Re: Is this a case of ischemic hepatitis presenting as acute abdomen??

Dear Editor

I read with interest this case of ischaemic hepatitis mimicking intestinal ischemia by Powell et al.[1]

This patient who presented with upper GI bleeding for three days, was in hypovolemic shock as initial examination revealed tachycardia, tachypnoea, hypotension and severe anaemia. This was certainly due to an upper GI bleed from the acute duodenal ulcer found on endoscopy. The shock was sufficient to cause lactic acidosis. Melaena can be easily explained by upper GI bleeding . This shock state by itself is sufficient to cause non-occlusive mesenteric ischaemia (NOMI) due to intestinal vasoconstriction and ischaemic hepatitis that can explain the acute abdominal signs and typical course of liver enzymes. While the course of NOMI may be self-limited as in this case, elderly and diabetic patients, as well as those developing ischaemia following aortic surgery or hypotension, continue to have a poor prognosis.[2] So my impression on reading this case was acute hypovolemic shock due to an upper GI bleed secondary to acute duodenal ulcer causing lactic acidosis, non-occlusive mesenteric ischaemia and ischaemic hepatitis. I do not understand why the authors have put the entire presentation as a case of ischaemic hepatitis presenting as an acute abdomen when in fact the patient presented with an upper GI bleed and went on to develop the obvious sequelae of NOMI and ischaemic hepatitis. In fact it is important to recognise NOMI in shock states because in cases not responding to restoring intravascular volume and haemodynamic stability, angiographic papaverine infusion into superior mesenteric artery or peripheral infusion of glucagons can be tried.[3] Operative therapy is reserved for resection of necrotic bowel.[3]

References

(1) L Powell, S Tesfaye, R Ackroyd, and D S Sanders. Surgical presentation of ischaemic hepatitis. Postgrad Med J 2003; 79: 350-351.

(2) Longo WE, Ballantyne GH, Gusberg RJ. Ischemic colitis: patterns and prognosis. Dis Colon Rectum. 1992 Aug; 35(8): 726-30.