Sickle Cell Hepatopathy

Sickle Cell Disease (SCD) is terrible, and we are well versed in many of the common presentations. Pain and fever complaints dominate the majority of the encounters in the ED; however, let us not overlook the potential impact SCD has on all organ systems: leading to a wide variety of complications from Priapism to Acute Chest Syndrome and to Splenic Sequestration. Even Sickle Cell Trait can lead to complications! This week, I had the pleasure of being at the ACEP/AAP Advanced Ped EM Assembly (make sure to consider joining us next March in New York) where Dr. Ilene Claudius reminded me of another important set of complications caused by SCD. Let’s take a moment to review this potentially life-threatening complication of SCD – Sickle Cell Hepatopathy:

Sickle Cell Hepatobiliary Complications 

  • Hepatobiliary system is one of the most common intra-abdominal organsadversely affected by SCD. [Shah, 2017]
    • Evident in 10-40%of sickle cell crisis cases.
  • Basic pathophysiology components: [Shah, 2017]
    • Increased RBC destruction leads to increased bilirubin processing.
    • Intrahepatic sickling of RBCs leads to sinusoidal obstruction.
    • Microvascular obstruction and stasis and local hypoxia lead to acute and chronic problems.
  • Each Hepatobiliary Complication can generate a wide spectrum of presentations, from mild and transient to fulminant and life-threatening. [Shah, 2017]
  • Individual Hepatobiliary Complications can be difficult to classifyas there can be substantial overlap between conditions. [Pecker, 2018;Shah, 2017]

Sickle Cell Hepatobiliary Complications: Chronic [Shah, 2017

  • Iron Overload
    • Consequence of accumulation of transfused iron, continued hemolysis, and increased GI absorption.
    • Can be asymptomatic or lead to cirrhosis.
  • Gallstone Disease [Simon, 2016]
    • Common in patients with SCD (~25-58% in patients 10 years to 65 years of age) 
    • Cholecystectomy is the most common surgical procedure in patients with SCD. 
  • Viral Hepatitis 
    • SCD patients have higher prevalence of viral hepatitis.
    • Can present similarly to other patients with viral hepatitis but can also exacerbate one of the other complications.
  • Sickle Cell Cholangiopathy 
    • Due to ischemic injury to the biliary (ischemic cholangiopathy).
    • Leads to obstructive jaundice, itching, and cholestatic LFTs.

Sickle Cell Hepatobiliary Complications: Acute [Pecker 2018;Shah, 2017

  • Sickle Cell Hepatopathy” [Pecker, 2018;Shah, 2017]
    • Term referring to liver dysfunction and hyperbilirubinemia due to intrahepatic sickling process.
    • Leads to local ischemia, sequestration, and cholestasis.
    • Chronic liver disease may confound acute changes, so judge current lab results against prior ones if available. [Simon, 2016]
    • Also associated with Sepsis, Viral Hepatitis, Autoimmune Disease, and Iron Overload. [Pecker, 2018]
  • Degree of sickling and severity of obstruction produce spectrum of acute injurythat includes:
    • Acute Sickle Cell Hepatic Crisis[Shah, 2017; Simon, 2016]
      • Seen in ~10 %of patients presenting with vaso-occlusive crisis.
      • May present like acute cholecystitis (fever, RUQ pain), but has concurrent hepatomegaly.
      • ALT/AST range from normal to 3 x normal levels. 
      • Elevated bilirubin (mostly conjugated) but < 15 mg/dL.
      • Tx: Supportive care with hydration and treatment of vaso-occlusive crisis.
    • Acute Hepatic Sequestration[Shah, 2017]
      • Large amount of RBC entrapped in liver
      • Massive dilation of sinusoids compressing the biliary tree. 
      • Abrupt onset of severe RUQ pain, rapid increase in liver size, acute worsening anemia.
      • May present with overt shockdue to acute fall in hematocrit.
      • Significant hyperbilirubinemia(up to 24 mg/dL).
      • Alkaline phosphatase can rise up to 650 IU/L. ALT/AST are usually normal.
      • Tx:
        • Supportive care and resuscitation. 
        • Transfusion vs Exchange Transfusion (being careful to not cause Hyperviscosity Syndrome once liver releases trapped RBCs)
    • Acute Intrahepatic Cholestasis[Shah, 2017; Simon, 2016]
      • May be fatal! Fortunately, rare.
      • Wide-spread ischemia.
      • Severe acute hepatic crisisthat can progress to multi-organ failure.
        • Acute liver failure
        • Renal failure
        • Encephalopathy
        • Coagulopathy
      • Severely elevated bilirubin (mostly conjugated)up to 200’s mg/dL.
      • ALT/AST elevated > 1000 mg/dL.
      • Alkaline phosphatase can be normal or elevated (>1000 IU/L).
      • Tx:
        • Supportive care (like antibiotics!)and resuscitation! [Pecker, 2018]
        • Exchange transfusion
        • Correction of coagulopathywith FFP.
        • Dialysis for renal impairment.
        • May require liver transplantation. [Pecker, 2018]

Moral of the Morsel

  • Sickle Cell Disease SUCKS!  Constant ischemia and infarcts not only cause pain but complicate the function of all of the organs. 
  • Fever and RUQ isn’t always Cholecystitis?Make sure you keep Sickle Cell Hepatopathy on your list of considerations!
  • Don’t Make them Thick! Transfusion of RBCs in a patient with SCD should always be done carefully and with consideration of possibly causing Hyperviscosity Syndrome. Consult your friendly pediatric hematologist!
  • Don’t forget the bug juice!The febrile sickle cell patient still needs us to consider bacterial infection high on their problem list!

References

Pecker LH1, Patel N2, Creary S3, Darbari A4, Meier ER5, Darbari DS6, Fasano RM7. Diverse manifestations of acute sickle cell hepatopathy in pediatric patients with sickle cell disease: A case series. Pediatr Blood Cancer. 2018 Aug;65(8):e27060. PMID: 29667721. [PubMed] [Read by QxMD]
Kwun Lui S1, Krasinskas A1, Shah R1, Tracht JM1. Orthotropic Liver Transplantation for Acute Intrahepatic Cholestasis in Sickle Cell Disease: Clinical and Histopathologic Features of a Rare Case. Int J Surg Pathol. 2018 Sep 10:1066896918798467. PMID: 30198363. [PubMed] [Read by QxMD]
Shah R1, Taborda C1, Chawla S1. Acute and chronic hepatobiliary manifestations of sickle cell disease: A review. World J Gastrointest Pathophysiol. 2017 Aug 15;8(3):108-116. PMID: 28868180. [PubMed] [Read by QxMD]
Simon E1, Long B1, Koyfman A2. Emergency Medicine Management of Sickle Cell Disease Complications: An Evidence-Based Update. J Emerg Med. 2016 Oct;51(4):370-381. PMID: 27553919. [PubMed] [Read by QxMD]
Papafragkakis H1, Ona MA2, Changela K2, Sadanandan S3, Jelin A4, Anand S2, Duddempudi S2. Acute liver function decompensation in a patient with sickle cell disease managed with exchange transfusion and endoscopic retrograde cholangiography. Therap Adv Gastroenterol. 2014 Sep;7(5):217-23. PMID: 25177368. [PubMed] [Read by QxMD]
Ahn H1, Li CS, Wang W. Sickle cell hepatopathy: clinical presentation, treatment, and outcome in pediatric and adult patients. Pediatr Blood Cancer. 2005 Aug;45(2):184-90. PMID: 15747337. [PubMed] [Read by QxMD]
Khurshid I1, Anderson L, Downie GH, Pape GS. Sickle cell disease, extreme hyperbilirubinemia, and pericardial tamponade: case report and review of the literature. Crit Care Med. 2002 Oct;30(10):2363-7. PMID: 12394969. [PubMed] [Read by QxMD]
Shao SH1, Orringer EP. Sickle cell intrahepatic cholestasis: approach to a difficult problem. Am J Gastroenterol. 1995 Nov;90(11):2048-50. PMID: 7485022. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.