Chronic Passive Congestion - LiverBONDOC, JOHN BENEDICT V.

MD 2G

CongestionIt is an engorgement of an organ with venous blood.

Systemic Congestion = Heart FailureLocalized Congestion = Isolated venous obstruction

Chronic Passive Congestion - LiverIt occurs when congestive heart failure increases the back-pressure in the peripheral venous circulation, impeding venous outflow from the liver.

Etiology of CPC LiverSystemic: Congestive Heart Failure

Before: Rheumatic Heart FailureNow: Right-Sided Heart Failure

Local: Occlusion of Inferior Vena Cava and Hepatic Vein

PresenterPresentation Notesbefore is now prevented due to.Advent of surgical valveDecline in the prevalence of rheumatic fever

Pathogenesis

Right Sided Heart Failure

Back pressure from the

right heart, IVC &

hepatic veins tohepatic

sinusoids

Sinusoidal dilatation

Physical damage to

hepatocytes due to severe

hypoxia

PresenterPresentation NotesLeft sided heart failure or shock = hepatic hypoperfusion and hypoxia causing ischemic coagulative necrosis of hepatocyte in the central region of the lobule (centrilobular necrosis)

Gross MorphologyLiver is enlarged, tender, cyanotic with rounded edgesCapsule is tenseNutmeg liver = centrilobular regions: red and brown mottled appearance and slightly depressed (accentuated lobular pattern of alternating light and dark areas)

PresenterPresentation NotesMottled appearance: RED = congested center of lobules BROWN = congested peripheral zoneSlightly depressed = due to cell death

Microscopic MorphologyCentrilobular Zone: degenerative changes leading to ischemic necrosisdilated central vein, centrilobular hemorrhage, hemosiderin-laden macrophages, variable degrees of hepatocyte pressure atrophy, dropout and necrosisPeripheral Zone: fatty changes

PresenterPresentation NotesCentrilobular Zone more affected, less blood supply from hepatic arteriesPeripheral Zone less affected, more perfuse blood(prolonged case: thickening of central veins and centrilobular fibrosis) (extreme case: generalized fibrosis cardiac cirrhosis)Extreme cases: constrictive pericarditis or tricuspid stenosis

Acute CPC: central vein and sinusoids are distended

Pictures taken from: http://www.pathologyatlas.ro/passive-congestion-liver.php

PresenterPresentation NotesArrow: Dilated SinusoidsBlue: Fibrosis from central vein (late changes)

Laboratory FindingsMild increase in aminotransferasesMild hyperbilirubinemiaLiver function usually within reference ranges

Clinical ManifestationsRarely affects hepatic functionInfrequently features portal hypertension (ascites and splenomegaly) may develop Mild to moderate jaundice

ReferencesRubins Pathology Clinicopathologic Foundations of Medicine 7th EditionRobbins and Cotran Pathologic Basis of Disease 9th EditionTextbook of Pathology 6th Edition by Mohan

Chronic Passive Congestion - LiverCongestionChronic Passive Congestion - LiverEtiology of CPC LiverPathogenesisSlide Number 6Gross MorphologySlide Number 8Microscopic MorphologySlide Number 10Slide Number 11Slide Number 12Laboratory FindingsClinical ManifestationsReferences