Internal Medicine

Congested liver

definition

In the case of congested liver, the blood backs up in the liver because it can no longer drain through the liver veins.
The cause of a congested liver is a weak right heart (heart failure). The heart can no longer pump the blood from the liver into the lungs. The blood backs up in the liver. This changes the liver tissue significantly. The liver cells die and cirrhosis develops, which can lead to liver failure.

Causes of congested liver

A congested liver is a serious and threatening disease. The cause of the development of a congestive liver is usually not in the liver, but in the heart, more precisely the right half of the heart.
This is where the blood from the body (including the liver, but also from the vena cava) should actually be pumped into the lungs. With right heart weakness, the blood looks back into the organs. This also happens when the hepatic veins are blocked by thrombosis (Budd-Chiari syndrome).

The tissue changes due to the constant pressure of the blood column. In the course of the congestion liver cirrhosis develops.

Read more about the rare liver disease: Budd-Chiari Syndrome

Congestive liver due to heart failure

The cause of a congested liver is a weakness of the right heart. This is also called right heart failure in technical terms. Right heart failure can have many causes. For example, it can develop with lung disease.

The right heart always has to pump against the increased pressure in the pulmonary circulation (pulmonary hypertension) and gets tired. This is also the case with valvular heart disease such as narrowing of the pulmonary valve.

Right heart failure can also be present together with left heart failure, in which case the heart muscle weakness usually arises from various heart attacks or an inflammation of the heart muscle. The consequences are always the same; Due to the heart's insufficient pumping capacity, the blood backs up in the organs, including the liver.

also read: Heart failure - you should know that

What are the symptoms of a congested liver?

In the early stages of a congestive liver, the symptoms are relatively unspecific. Those affected complain of tiredness, exhaustion and a general feeling of illness.

If the disease progresses, the typical symptoms of liver dysfunction develop with jaundice (jaundice), protein deficiency, blood clotting disorders and, in the end-stage, liver coma (hepatic encephalopathy).

The right heart weakness also causes problems for the patient, the water not only backs up in the liver, but also in the upper and lower vena cava. The result is swollen neck veins and very pronounced leg edema. Of course, this goes hand in hand with a general reduction in performance.

Pain in a congested liver

Pain is not necessarily one of the typical symptoms of a congestive liver.

However, capsule distension may occur. The liver capsule is very sensitive to pain. Due to the pressure of the venous congestion, which cannot be pumped any further, it is possible that the liver initially swells. This increases the volume of the liver and the tissue presses on the liver capsule that surrounds it. This can be quite painful.

Sometimes this is also noticed during the physical exam. Palpation of the liver causes the patient to jerk painfully.

Water in the stomach with a congestive liver

Water in the abdomen, or ascites, as it is known in technical terms, is a well-known complication of liver disease. It manifests itself in a balloon-like belly.

In congestive liver, it develops when the disease has progressed so far that liver cirrhosis is present. In cirrhosis of the liver, connective tissue is remodeled in the liver. The blood from the portal vein can no longer flow as well through the liver because the connective tissue prevents blood flow. Therefore, the blood backs up in front of the liver in the abdomen (= portal hypertension).

Ascites is therefore always a sign that cirrhosis of the liver must already be present.

Learn more at: Water in the stomach

Diagnosis of congested liver

The diagnosis of congested liver can be made relatively easily. On the one hand, the anamnesis shows the typical symptoms of right heart failure and liver dysfunction (see below). A congestion of the neck veins is also usually visible on the physical examination; if the disease is advanced, there are already signs of cirrhosis, such as Water in the abdomen (ascites).

The laboratory chemical examination shows an increase in liver values and an increased pro-BNP as a marker for heart failure. An ultrasound scan of the liver confirms the suspicion; here one can clearly see the congestion of the liver veins. Furthermore, an ultrasound examination of the heart should be carried out in order to be able to assess the pumping function of the right heart.

Ultrasound of the liver

Sonography (ultrasound) of the liver is a good way to diagnose congestive liver.
The congested hepatic veins are clearly widened, this can be seen both in the hepatic vein star and in the surrounding area. The inferior vena cava is also significantly widened. The respiratory modulation is canceled, i.e. the diameter of the blood vessels no longer changes with inhalation and exhalation. The blood vessels are always maximally wide due to the high filling pressure.

The tissue of the liver itself can also be assessed well with sonography. Depending on the severity of the damage, a typical picture emerges in the sonography.

MRI of the liver

An MRI of the liver for congestive liver is actually rarely necessary. Most of the time, the diagnosis can be clearly made using sonography.

If, on the other hand, the right heart pumps normally and the cause of the congestive liver is suspected to be an occlusion of the liver veins due to thrombosis (Budd-Chiari Syndrome), an MRI scan of the liver can make sense. Because in this way one can show the further course of the liver veins and recognize thrombotic occlusions of the vessels.

Read more about the rare liver disease: Budd-Chiari Syndrome

With a regular congestive liver in the context of a right heart failure, an MRI examination of the liver does not have to be performed.

Learn more at: MRI of the liver

Laboratory values for a congested liver

An increase in liver values, especially in transaminases, is always typical of congestive liver. If the transaminase increase is due to congestion, then the GOT is usually higher than the GPT. Often the values are only slightly increased, but they can also go up into the thousands.

With increasing liver dysfunction, there is also an increase in bilirubin. The Quick value drops. The ammonia level in the blood may be increased. A marker for heart failure is pro-BNP, which can also be measured in the blood. In right heart failure it would be increased.

Read on under: Increased liver values

Therapy of congestive liver

A congested liver can only be treated by eliminating the underlying cause. In most cases, there is no liver disease. The congested liver is caused by right heart failure. So you have to treat this right heart failure.
Right heart failure also has various causes, all of which can / must be treated differently. This is the domain of the cardiologist. As a specialist in gastrointestinal and liver diseases, the gastroenterologist can do little with a congestive liver caused by stress on the right heart.

In rare cases, congestive liver is also triggered by thrombosis in the hepatic veins. In this case one speaks of the Budd-Chiari syndrome. Patients need blood thinning (anticoagulation). If the liver congestion does not improve, a portosystemic shunt (TIPS) can be considered, which bypasses blood to the liver.

If the cause of a congested liver cannot be corrected in time, cirrhosis of the liver develops as a complication. The complications of this disease must then also be treated.

You can also find out more at: Therapy of heart failure

Prognosis in congestive liver

The prognosis of the congestive liver depends on the cause.It is important to be able to treat the cause and thus prevent progression into cirrhosis of the liver. However, this is often very difficult. Therefore, the disease usually progresses and cirrhosis of the liver develops.

The prognosis for cirrhosis of the liver depends on the stage of the cirrhosis and the complications. Common complications include bleeding from varicose veins around the esophagus and stomach. Here the mortality per bleeding event is almost 40%.

Course of the disease in congestive liver

The course of the disease depends on the cause. If the cause of the right heart strain can be treated well and the right heart pumps better again, then the blood congestion in the liver also decreases and the disease improves.

In most cases, however, it is a chronic weakness of the right heart that is difficult to treat. In this case, the dreaded complication of liver cirrhosis develops over time, which often ends in death due to numerous complications.

Cirrhosis of the liver due to congestive liver

Patients with congestive liver are at high risk of developing liver cirrhosis. This is understood as the connective tissue remodeling with scarred shrinkage of the organ. This almost leads to a complete loss of function (liver failure). The process is not reversible (irreversible).

Similar to years of chronic alcohol consumption, patients with liver cirrhosis have a high risk of complications due to congestive liver, such as bleeding from varicose veins in the esophagus (esophageal varices) or the stomach (fundic varices). Therefore, in patients with congestive liver, everything should be done to optimize the cardiac output in order to prevent the development of liver cirrhosis.

Learn more at:

Can cirrhosis of the liver be cured?
Esophageal varices

What is the difference between a chronic and an acute congestive liver?

In acute congestive liver, venous backflow of the blood into the liver occurs relatively suddenly. For example, right heart function is suddenly so severely restricted by a pulmonary artery embolism that the blood congests in front of the liver. This causes the liver to swell and enlarge.
Under the microscope you can see the significantly enlarged venous blood vessels in the liver tissue. If the cause of the right heart strain is eliminated (= treatment of pulmonary artery embolism), liver function usually improves again.

In the case of chronic congested liver, the congestion develops insidiously and lasts for months. This is where the beginning of the connective tissue remodeling of the liver begins. This can also be seen under the microscope. It is a sign of cirrhosis of the liver. It is no longer reversible and continues to progress in the further course.