February 8, 2016

Shocking Facts of Shock Liver

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“Patient with transaminitis, keep watching labs.”

“Patient’s liver enzymes extremely elevated, keep in ICU.”

Physicians may have seen these notes before. But transaminitis and “extremely elevated liver enzymes” do not equate to shock liver or acute and subacute hepatic failure without coma. 

Shock liver, also known as ischemic hepatitis, is used to describe a syndrome that occurs after a period of significant hypovolemia and/or hypotension. Perfusion to the liver is impaired, resulting in damage to the liver cells, and this is reflected in rapid elevation of transaminases. Other elevated lab values may be LDH, serum creatinine, BUN, INR, and ammonia. Although this is rare, it can be a life-threatening complication. 

The most common cause of this condition is shock or hypotension, but it also can be caused by sickle cell crisis, hypoxia, heart failure, arrhythmia, severe asthma, or pulmonary disease. It also can be drug-induced (by acetaminophen, aspirin, niacin, IV amiodarone, methotrexate, etc.) after general anesthesia, propofol, or thrombosis of the hepatic artery and portal vein, which provides oxygen-rich blood to the liver. These patients may report right upper quadrant pain, which could indicate a potential thrombus. The patient may report feeling weak and lightheaded or may have nausea and vomiting, anorexia, or malaise. The liver may be enlarged and tender, other symptoms that tend to reflect the underlying cause. Jaundice may be present, but it is rare and usually transient. Treatment is aimed at the underlying cause of the ischemia, and patients usually recover.

Criteria for the diagnosis would include latency of less than 14 days, sudden onset of symptoms, alanine aminotransferase (ALT) of more than 20 times the upper limits of normal, alkaline phosphatase (ALP) that are normal or less than two times ULN, bilirubin of less than 10 mg/dL at time of diagnosis, and acute injury/dysfunction of other organ systems (lungs, kidneys, bone marrow, etc.). If liver biopsy is taken, changes of acute zone 3 coagulative necrosis with scant lobular lymphocytic infiltration, little or no fibrosis or cholestasis, and no veno-occlusive changes may be present.   

An elevation in the ALT of 400-800 U/L may be considered probable as well. The levels will steadily return to normal levels in about 7-10 days. Outcome will be determined in part by the severity of liver dysfunction and the etiology and severity of the underlying cause.

Treatment will be focused on the underlying cause of the ischemia and would include intravenous hydration, possible antibiotics (in the case of sepsis), monitoring of mechanical ventilation, catecholamines, and metabolic monitoring. Ischemic hepatitis usually resolves with treatment of the underlying cause.

Coding of “Shock Liver"

ICD-10 has no coding option of shock liver or ischemic hepatitis. Due to the necrosis that occurs from lack of blood supply, this is where we would start, resulting in the code K72.00, acute and subacute hepatic failure without coma, an MCC. The fifth digit indicates with or without coma. 

Excluded with this diagnosis is alcoholic hepatic failure (K70.4), hepatic failure with toxic liver disease (K71.1-), icterus of newborn (P55-P59), postprocedural hepatic failure (K91.82), and viral hepatitis with hepatic coma (B15-B19). 

However, there is an ICD-10 Coding Clinic edition that addresses shock liver: 

Question: A patient was admitted to our facility with acute-on-chronic systolic heart failure and found to be in cardiogenic shock with acute renal failure and acidosis. The physician documented that the patient had “shock liver” as well. What is the correct diagnosis code for shock liver in ICD–10-CM?

Answer: Assign code K72.0-, Acute and subacute hepatic failure, for shock liver. The assignment of the fifth digit would be dependent on the presence or absence of coma.

Querying for Shock Liver

The following is a query example: 

A 65-year-old male is placed in ICU for treatment of sepsis with hypotension, PMH of heart failure, asthma, and OSA. On admit the BP was 70/54, oxygen saturation was 84 percent on room air. ALT was 28, AST 14, ALP 86, and bilirubin 0.2. The next day, the patient c/o nausea and was vomiting. Physical exam noted an enlarged and tender liver, ALT was 1850, Alk P 263, bilirubin was 3. Treatment included multiple IV fluid boluses, norepinephrine drip, and IV antibiotics. The patient was placed on a nonrebreather mask. Blood sugar was monitored. Physician noted severe abnormal LFTs and severe sepsis. Please note the relevance of these findings:

  1. Liver failure
  2. Acute or subacute liver necrosis due to severe sepsis and hypotension
  3. Other, please specify
  4. None of the above 

The MS-DRG would be 871 septicemia or severe sepsis w/o MV >96 hours w/ MCC. The relative weight would be 1.7926, LOS 5.0, SOI 2, and ROM 3. If the physician responded with the answer of acute or subacute liver necrosis due to severe sepsis and hypotension (K72.00, MCC), the RW and LOS would not change. However, the SOI would increase from 2 to 3 and the ROM from 3 to 4. 

The shocking fact is that acute liver necrosis is often overlooked and underdiagnosed. The purpose of this article is to make the clinical documentation improvement (CDI) specialist aware of this potential diagnosis, signs and symptoms, and possible treatment. 

As noted above, it can have significant impact on the final severity of illness and risk of mortality, and if it is the only MCC, it would impact the MS-DRG, relative weight, and length of stay.

About the Author

Tina Ferguson is a senior healthcare consultant for Panacea Healthcare Solutions. She has more than 11 years in clinical nursing, clinical documentation improvement and chart auditing. In her role Tina performs clinical documentation improvement audits that focus on clinical documentation improvement opportunities related to severity of illness, risk of mortality and quality.  Formerly, she was a remote nurse auditor for a recovery auditor.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Tina Ferguson, RN, CCDS

Tina Ferguson is a senior healthcare consultant for Panacea Healthcare Solutions. She has more than 11 years in clinical nursing, clinical documentation improvement and chart auditing. In her role Tina performs clinical documentation improvement audits that focus on clinical documentation improvement opportunities related to severity of illness, risk of mortality and quality. Formerly, she was a remote nurse auditor for a recovery auditor.

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