Ischemic Hepatopathy Without Shock: A Complication of Pancreatitis

While ischemic hepatopathy is most commonly associated with systemic hypotension or cardiac failure, it may also occur in the setting of microvascular compromise secondary to severe systemic inflammation. Ischemic hepatopathy is characterized by acute, marked elevations in aminotransferase levels with minimal cholestasis and rapid biochemical recovery. Although acute pancreatitis is a recognized trigger of disseminated intravascular coagulation (DIC), hepatic ischemia resulting from this complication is rarely reported. We present the case of a 49-year-old man with acute-on-chronic pancreatitis who developed extreme transaminase elevation (aspartate aminotransferase (AST) > 10,000 IU/L), severe thrombocytopenia, and coagulopathy in the absence of hypotension or hepatic encephalopathy. An extensive evaluation excluded viral, autoimmune, toxic, metabolic, and obstructive etiologies, as well as hemophagocytic lymphohistiocytosis (HLH). Liver enzyme levels improved rapidly with supportive care and N-acetylcysteine therapy. This case highlights pancreatitis-associated ischemic hepatopathy as an important diagnostic consideration in patients presenting with marked aminotransferase elevation.