Hepartic infarction is an extremely rare situation because of the liver's dual blood supply by the hepatic artery and portal vein. Hepatic infarction can occur when there is both hepatic arterial and portal vein flow compromise but most cases are due to acute portal venous flow compromise 11.
Most cases are seen after liver transplantation or hepatobiliary surgery. Non-transplant cases are mostly caused by 1-2:
- hepatic artery occlusion due to
- infarction without hepatic artery occlusion is mainly caused by
- acute shock state
- hypercoagulable state
- preeclampsia, eclampsia and post-partum HELLP syndrome 4-10.
- complication of anesthesia
Clinically these patient present with abdominal pain, nausea, vomiting and abnormal liver function tests 2. Most of the time, infarction is a peripherally located wedge-shaped area, however it can be centrally or round or oval shape 2.
- acute stage
- an ill defined hypoechoic area with indistinct border
- gas within sterile infarcted zone can be seen 2-3
- chronic stage
- infarcted area becomes anechoic and cystic with distinct borders.
Differentiation between gas within sterile infarcted area and abcess formation by imaging is impossible and fine needle aspiration is needed 2.
Typically infarction presents as an ill-defined wedge-shaped based area of hypo attenuation which is mostly peripheral without pressure effect on adjacent structures in post-contrast images 4-5.
On MRI imaging, regions of hepatic infarction appears as hypo-intense lesion on T1 imaging, with hyper-intensity on T2 imaging 6.
General imaging differential considerations include:
- focal fatty infiltration: although focal fatty infiltration lacks pressure effect, vessels are seen crossing trough the lesion
- hepatic abscess: typically shows pressure effect on adjacent structures and ring enhancement while hepatic infarction lacks pressure effect and any enhancement
- true hepatic masses: both pressure effect and enhancement differentiates from hepatic infarction. the clinical scenario is different
- 1. Peterson IM, Neumann CH. Focal hepatic infarction with bile lake formation. AJR Am J Roentgenol. 1984;142 (6): 1155-6. doi:10.2214/ajr.142.6.1155 - Pubmed citation
- 2. Lev-Toaff AS, Friedman AC, Cohen LM et-al. Hepatic infarcts: new observations by CT and sonography. AJR Am J Roentgenol. 1987;149 (1): 87-90. doi:10.2214/ajr.149.1.87 - Pubmed citation
- 3. Doppman JL, Dunnick NR, Girton M et-al. Bile duct cysts secondary to liver infarcts: report of a case and experimental production by small vessel hepatic artery occlusion. Radiology. 1979;130 (1): 1-5. Pubmed citation
- 4. Zissin R, Yaffe D, Fejgin M et-al. Hepatic infarction in preeclampsia as part of the HELLP syndrome: CT appearance. Abdom Imaging. 1999;24 (6): 594-6. Pubmed citation
- 5. Holbert BL, Baron RL, Dodd GD. Hepatic infarction caused by arterial insufficiency: spectrum and evolution of CT findings. AJR Am J Roentgenol. 1996;166 (4): 815-20. doi:10.2214/ajr.166.4.8610556 - Pubmed citation
- 6. Boll DT, Merkle EM. Diffuse liver disease: strategies for hepatic CT and MR imaging. Radiographics. 2009;29 (6): 1591-614. Radiographics (full text) - doi:10.1148/rg.296095513 - Pubmed citation
- 7. Adler DD, Glazer GM, Silver TM. Computed tomography of liver infarction. AJR Am J Roentgenol. 1984;142 (2): 315-8. doi:10.2214/ajr.142.2.315 - Pubmed citation
- 8. Giovine S, Pinto A, Crispano S et-al. Retrospective study of 23 cases of hepatic infarction: CT findings and pathological correlations. Radiol Med. 2006;111 (1): 11-21. Pubmed citation
- 9. Smith GS, Birnbaum BA, Jacobs JE. Hepatic infarction secondary to arterial insufficiency in native livers: CT findings in 10 patients. Radiology. 1998;208 (1): 223-9. Pubmed citation
- 10. Kronthal AJ, Fishman EK, Kuhlman JE et-al. Hepatic infarction in preeclampsia. Radiology. 1991;177 (3): 726-8. Pubmed citation
- 11. CT of the Acute Abdomen. Springer. ISBN:3540892311. Read it at Google Books - Find it at Amazon