Ischemic Hepatitis Secondary to Obstructive Sleep Apnea (OSA)

Abstract

Purpose: Ischemic hepatitis refers to diffuse hepatic injury which results from imbalance between hepatic oxygen supply and demand. Patients with OSA have recurrent episodes of respiratory airflow obstruction secondary to upper airway collapse during sleep. Ischemic hepatitis may, therefore, occur secondary to severe arterial hypoxemia as a result of OSA. We report a case of a patient with class III obesity with acute liver injury secondary to OSA induced hypoxemia. Methods: A 53 year old Caucasian male with class III obesity and history of OSA was admitted with lower extremity cellulitis. The patient was afebrile, hemodynamically stable with oxygen saturation of 87% on room air. Laboratory studies were significant for elevated liver transaminases with AST 1020, ALT 2202. Total bilirubin was 0.9, direct bilirubin 0.4 and alkaline phosphatase was within normal limits. History did not suggest viral, autoimmune or drug-induced hepatitis. Autoimmune markers and serologies for hepatitis A, B and C were negative. There was no clinical evidence of cardiac failure. Results: Echocardiogram showed normal left and right systolic function. Right heart catheterization revealed normal pulmonary artery and wedge pressures. Hepatic portal vein gradient was normal. A transjugular liver biopsy was performed. Histopathology showed zone 3 hepatocellular necrosis, and mildly active steatohepatitis without fibrosis. Nocturnal pulse oximetry showed multiple and profound desaturations. The cumulative time spent at saturation <85% was 87%. The patient was started on CPAP and supplemental oxygen to maintain optimal saturation during sleep. Liver enzymes improved over the next few days and eventually completely normalized. On a 3 month follow-up, the patient continues to use CPAP machine with significant improvement in nocturnal pulse oximetry. He has been enrolled in a weight reduction program and is undergoing evaluation for bariatric surgery. Conclusion: Ischemic hepatitis is a rare manifestation of OSA secondary to severe arterial hypoxemia. This entity should be considered in the differential diagnosis of ischemic liver injury. Institution of correct management strategies and prevention of complications of OSA can result in prevention of a potentially fatal acute liver injury.Figure: Graph of Liver Transaminases