OGH Reports 2017; 6(1): 28-30Peer Reviewed Journal in Oncology, Gastroenterology and Hepatologywww.oghreports.org | www.journalonweb.com/ogh

OGH Reports, Vol 6, Issue 1, Jan-Jun, 2017 28

Case Report

INTRODUCTIONChronic right sided congestive heart failure may cause chronic liver injury and cirrhosis of liver but is very uncommon. In long term right heart failure there is elevated venous pressure that is transmitted to liver sinusoids via inferior vena cava and hepatic veins. This leads to long term passive congestion and relative ischemia due to poor circulation eventually leading to necrosis and fibrosis of liver predominantly of centrilobular region. Patient generally presents with clinical features of congestive heart failure and portal hypertension but very rarely presents with variceal hemorrhage or encephalopathy.[1]

But our case patient presented with evidence of variceal hemorrhage. Also the overall prognosis of cardiac cirrhosis is not well established and treatment of cardiac cirrhosis is mainly aimed at managing underlying heart failure so it becomes important to distinguish it from other cause of cirrhosis.[1]

CASE HISTORYA 50 year male, farmer, chronic smoker presented with progressively increasing abdominal distension for last 6 months, malena for 2 months, Pedal edema for 1 month and constipation for 15 days and a episode of hematemesis. There was also history of anorexia, nausea and easy fatigability and presently presented due to massive abdominal distension leading to diffi­culty in breathing and episode of hematemesis. On repeated enquiry he also revealed of chronic cough and breathlessness with winter exacerbation for last 10 years and episodes of pedal edema relieving after

Cardiac Cirrhosis–An Uncommon Manifestation of Common Disease

ABSTRACTBackground: Chronic Right Heart failure is known to cause Liver Cirrhosis but it is rare. Here we are reporting the case of cardiac cirrhosis presented to us with signs of Liver Failure. Case Report : 50 year male, farmer, chronic smoker presented with progressive abdominal distension and episodes of malena since 6 months and an episode of hematemasis. On work up Liver cirrhosis was diagnosed but cause for cirrhosis was not established and on general examination pulse was irregular and features of pulmonary hypertension were present. On reviewing he revealed history of chronic cough and breathlessness with winter exacer-bations and pedal edema. Chest X-ray suggested cardiomegaly, ECG suggested low voltage complex with poor R wave progression and 2-D Echo suggested pulmonary hypertension with tricuspid regurgitation with right sided dysfunction suggesting cardiac cause for cirrhosis. Conclusion : Chronic Right Heart Failure is known but rare cause of Liver cirrhosis.Key words: Heart Failure, Cardiac Cirrhosis.

Jaideep Khare1*, Prachi Srivastava2, Jyoti Wadhwa1, Prasun Deb1

Jaideep Khare1*, Prachi Srivastava2, Jyoti Wadhwa1, Prasun Deb1

1Department of Endocrinology, Krishna Institute of Medical Sciences, Secunderabad, INDIA.2 Department of Dermatology, Krishna Institute of Medical Sciences, Secunderabad, INDIA..

Correspondence

Dr. Jaideep Khare, MD Medicine, DNB Super Speciality Resident, Dept. Of Endocrinology, Krishna Institute of Medical Sciences, Secunderabad, INDIA.

Phone no: 09177816611Email: drjaideepkhare@yahoo.com

History• Submission Date: 24-05-2016; • Review completed: 30-08-2016; • Accepted Date: 12-09-2016.

DOI : 10.5530/ogh.2017.6.1.7

Article Available online http://www.oghreports.org/v6/i1

Copyright© 2016 Phcog.Net. This is an open- access article distributed under the terms of the Creative Commons Attribution 4.0 International license.

Cite this article: Khare J, Srivastava P, Wadhwa J, Deb P. Cardiac Cirrhosis–An Uncommon Mani-festation of Common Disease. OGH Reports. 2017;6(1):28-30.

local medicine. There was no history of alcoholic intake, high risk sexual behaviour, Jaundice, tubercu­losis, long term drug or herbal intake, surgery or blood transfusion. There was no significant family history.

ExaminationOn general examination patient was cooperative and well oriented with poor nutrition. Pallor and Bi­Pedal pitting edema present. Cyanosis, clubbing, icterus, lymphadenopathy absent. Pulse­ 70/min irregular, normovolumic, normal in character and vessel wall normal.Blood pressure­ 100/ 70 mmHgNeck veins engorged and pulsatile and jugular venous pressure raised with CV wave form.On abdominal examination, abdomen was distended diffusely with eversion of umbilicus and prominent veins in flanks and epigastrium with blood flow from below upwards. Abdominal striae seen. There were no scar mark. No superficial tenderness pres­ent. Spleenomegaly of 4 c.m., firm, non­tender with smooth surface present. Liver not palpable no other lump present. Fluid thrill present.On cardiovascular examination precordium seemed to be normal. Apex beat in 5th intercostal space 2 cm. Lateral to mid clavicular line normal in character. Thrill or para­sternal heave absent. On auscultation 1st and 2nd heart sound audible with loud pulmonary component of 2nd heart sound. The holosystolic, high­pitched, blowing murmur of tricuspid insuffi­

Khare et al.: Cardiac Cirrhosis

OGH Reports, Vol 6, Issue 1, Jan-Jun, 2017 29

Figure 1: upper gastrointestinal endoscopy showing varices,

Figure 2: liver biopsy with showing fibrosis

ciency best heard at the lower left sternal border. The murmur intensifies with inspiration and decreases with expiration.On respiratory examination chest bilaterally symmetrical with decreased movement on both sides. Trachea central and no deformity of spine seen. Respiratory rate of 26 /min. With use of accessory muscles seen. Vocal fremitus equal on both side. Hyper­Resonant note heard on percussion. Bilaterally decreased breath sounds with diffuse rhonchi heard over lung fields. Vocal resonance decreased bilaterally.Nervous system examination reveals no abnormality.

InvestigationsHeamoglobin­ 8.9 gm/dl , Total leucocyte count­ 3,600/dl , Differential Leucocyte count­ neutrophil­ 48%, Lymphocytes­ 40%, Eosinophils­ 12%. Platelets count­ 87,000/dl.Random Blood sugar­93 gm/dl, Serum Sodium­139 mmol/lts, Serum Potassium­ 3.6 mmol/lits, Serum Urea­ 27 mg/dl, Serum Creatinine­ 0.7 mg/dlLiver Function Test­ S. Bilirubin­ 3.1 gm/dl, SALP­ 536 IU, SGOT­ 96 IU, SGPT­ 84 IU, Serum Protien—5.5 gm/dl, Serum Albumin­ 2.3 gm /dlAscitic Fluids Examination—TLC­ 90/ cc, DLC­ N30% L70% , Protien­ 0.9 gm/dl, SAAG­ 1.4Prothrombin concentration­ 71.6%, International Normalised Ratio­ 1.46Viral markers (HbSAg, HCV, HIV)—NegativeChest X­ray­ Cardiac Enlargement with accentuation of bronchovascu­lar marking and prominent central pulmonary vessels.ECG­ Rate of 70/min with irregular rhythm, Low voltage complexes with poor progression of R­ wavesABG­ pH­7.38 , pCO2­ 63, pO2­ 70, SPo2­ 84USG Abdomen­ Liver­ 12.16 cm, coarse , heterogeneous with irregu­lar capsule, Portal vein­13.9 mm & tortuous, Gross spleenomegaly—22.07 cm., Spleenic vein—13.2 mm ,tortuous & dialated with multiple collater­als in perihilar splenic region.Gross peritoneal collection.Upper G I Endoscopy­ Esophagus shows grade II × III columns of oesophageal varices and during procedure banding was done(Figure 1).Liver Biopsy­Suggestive of cirrhosis with bands of collage nous connective tissue (Figure 2).2­ D Echo­ Severe Tricuspid regurgitation, Severe Pulmonary Arterial Hypertension and Right atrium, dialated right ventricle (Figure 3).Pulmonary Function Test­ FEV1­ 52%, FVC­ 79% , FEV1/FVC­ 0.66 and improvement in FEV1 after use of bronchodilator was 7% suggesting of chronic obstructive airway disease stage II of GOLD criteria.

In hospital treatment-It consisted of Acute Management and Long term management­

Acute Management-Emergent endoscopy was done with banding of oesophageal varices to prevent further bleeding episode. Intravenous fluids administered cau­tiously to compensate for vascular fluid loss. Intravenous diuretics were given monitoring vitals of patient to relieve patient from symptoms of congestive heart failure. Nebulisation along with oxygen inhalation was given to patient to relieve broncho­constriction and breathlessness.

Long term management-Oral nitrates were advised to prevent further variceal bleeding as b­blockers are avoided in patients with respiratory airway diseases which were advised from other department. Oral diuretics prescribed containing Frusemide and Spironolactone combination. Liver supportive containing

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30 OGH Reports, Vol 6, Issue 1, Jan-Jun, 2017

Our case had Obstructive airway disease of stage II according to GOLD5 staging evidenced from deranged Pulmonary Function Test, Abnormal Blood Gas analysis. Evidence of Pulmonary hypertension was evident clinically in form of loud P2 and murmur of tricuspid regurgitation which was established on 2D Echocardiography. Chronic congestive heart failure established on long history of 10 years for which he taking treatment from quack of which records were not available.Presently he presented to us signs and symptoms of portal hypertension and congestive liver injury which was evident from spleenomegaly and progressive ascitis which was transudative with SAAG> 1.1,[6] Deranged Liver Function Test with markedly increased SALP. Metabolic and syn­thetic functions of liver were also compromised evident from decreased serum albumin and deranged PT/INR.[7] Spleenomegaly was associated with hyperspleenism as evident from pancytopenia in blood picture. Liver biopsy was done later after patient stabilisation and was suggestive of fibrotic changes establishing cirrhosis.Usually cases of cardiac cirrhosis not develop variceal bleeding, but our case presented with variceal bleeding evident from history of malena and an episode of hematemesis which was established on upper gastro­intestinal endoscopy in which therapeutic banding of varices was done.

Learning-A patient with Chronic Obstructive Lung Disease developing chronic right sided heart failure due to pulmonary hypertension causes passive congestion on hepatic veins leading to relative ischemia and eventually to hepatic necrosis and fibrosis and raised portal hypertension. Though variceal bleed is uncommon in portal hypertension due to cardiac cirrhosis but may be presenting complain in rare case as seen in our case. And also we highlight cardiac cause should be thought for differential diagnosis when patient presents with liver cirrhosis.

ACKNOWLEDGEMENTNone.

CONFLICT OF INTERESTDeclare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

REFERENCES1. Bacon BR. Cirrhosis and Its Complications. In: Longo D L,Kasper D L,

Jameson J L, editors. Harrison’s Principles of Internal Medicine 18th ed, NewYork:Mc Graw Hill; 2012;2;308 :P.2596–2597

2. Blumgart HL, Katzin H., “Cardiac cirrhosis” of the liver a clinical and pathological study. Trans Am Clin Climatol Assoc. 1938;54;82-86.

3. Sekiyama T, Nagano T, Aramaki T. [Congestive (cardiac) cirrhosis].  Nippon Rinsho. 1994;52(1):229–33.

4. Sekiyama T, Nagano T, Aramaki T. A clinic pathologic study of 1000 subjects at autopsy. Am J Pathol Aug. 1981;104(2):159–66.

5. Pauwels RA, Buist AS, Calverley PM. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHL-BI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med. 2001;163(5):1256–76. http://dx.doi.org/10.1164/ajrccm.163.5.2101039 ; PMid:11316667

6. Runyon BA. Cardiac ascites: A characterization. J Clin Gastroenterol. Aug 1988; 10(4):410–2. http://dx.doi.org/10.1097/00004836-198808000-00013; PMid:3418089

7. Kubo SH, Walter BA, John DH. Liver function abnormalities in chronic heart failure. Influence of systemic hemodynamic.  Arch Intern Med. 1987;147(7):1227–30. http://dx.doi.org/10.1001/archinte.147.7.1227 ; http://dx.doi.org/10.1001/archinte. 1987.00370070041006 ; PMid:3606280

sylimarine were also prescribed. Long acting b­agonist inhalers were given to relieve broncho­constriction. Proton pump inhibitor prescribed to reduce acid production and prevent further damage due to acid reflux. Lactulose prescribed to prevent constipation and related complications. Multivitamins with Iron and Folic acid were also prescribed.Patient educated regarding diet, precautions and follow up after discharge.

DISCUSSIONTerm cardiac cirrhosis denotes any type of hepatic fibrosis occurring in cardiac patient.[2] Our case report is in agreement with the previous observations of chronic liver injury due to long term congestive heart failure.Though the incidence of cardiac cirrhosis is low but causes for same are Ischemic heart disease, Cardiomyopathy, Valvular heart disease, Primary lung disease, Pericardial diseases. With decrease in incidence valvular heart disease, cardiomyopathy in etiology of cardiac cirrhosis has increased.[3]

Our case had primary lung disease due to chronic smoking which resulted in pulmonary arterial hypertension leading to chronic conges­tive heart failure. This further leads to passive congestion and relative ischemia due to poor circulation eventually leading to necrosis and fibrosis of liver predominantly of centrilobular region.[4] Usually cases of cardiac cirrhosis not develop variceal hemorrhage or encephalopathy but our case had unusual presentation of malena and hematemesis suggesting variceal bleeding.

Figure 3: 2D- Echocardiography showing grade 3 tricuspid regurgitation.

Cite this article: Khare J, Srivastava P, Wadhwa J, Deb P. Cardiac Cirrhosis–An Uncommon Manifestation of Common Disease. OGH Reports. 2017;6(1):28-30.