Ischaemic hepatitis in the elderly

BACKGROUND: Ischaemic hepatitis is centrilobular necrosis which is usually associated with an acute cardiovascular event and in a general hospital setting has been considered to be a rare condition. It is though thought to be frequently unrecognized, which is important as it has implications for both investigations and drug therapy. Previous reports have not focused on the elderly. OBJECTIVES: (1) To determine the incidence of ischaemic hepatitis in elderly patients admitted to a Department of Geriatric Medicine and (2) to assess both the clinical and biochemical features of the condition. METHODS: 1,905 elderly patients (1,270 F, 635 M) admitted consecutively to our department over a 2-year period were assessed prospectively. All were aged > or =65 years (mean 78, range 65-98). Ischaemic hepatitis was diagnosed by a rapid development of abnormal liver function tests of hepatocellular type in acutely ill patients in whom a fall in blood pressure occurred and other causes of liver dysfunction were excluded. The admission, lowest and subsequent blood pressures were recorded. Daily renal and liver function tests, including prothrombin times, were measured during the acute illness. RESULTS: Nineteen patients (1%) developed ischaemic hepatitis. The clinical picture was dominated by the causal condition, the commonest being left ventricular failure (12 patients). The mean fall in systolic, diastolic and mean blood pressures were 61, 44 and 48 mm Hg, respectively. Within 3 days the alanine aminotransferase increased to more than 5 times normal and there were marked elevations of the lactic dehydrogenase. In those who survived, the liver enzymes returned to normal within 7-22 days (mean 13). The prothrombin time was prolonged to >20 s in 6 patients (32%). Six patients died, 5 from left ventricular failure; the mean creatinine in 5 of those who died was 244 micromol/l (range 174-355) and in each the urea was >25 micromol/l. CONCLUSION: Ischaemic hepatitis is an uncommon but not rare condition in elderly patients admitted acutely to a Department of Geriatric Medicine. There was a dramatic rise in liver enzymes which in survivors returned to normal within 3 weeks. Clinical features were dominated by the causal condition and a third of the patients died.