A 50-year-old male patient with chronic chest pain for 3 hours presented to the emergency department of a local hospital on September 4, 2021. The patient was diagnosed with an acute myocardial infarction after a thorough examination. The patient had persistent hypotension and weak awareness, indicating he was in cardiogenic shock. He was consequently referred to the Affiliated Hangzhou First People's Hospital, followed by a sudden attack of ventricular tachycardia, ventricular fibrillation, and cardiopulmonary arrest with poor resuscitation. We performed extracorporeal membrane oxygenation (ECMO) and established extracorporeal life support after nearly 70 min of cardiopulmonary resuscitation. The patient was immediately given a coronary angiography, and ventricular fibrillation occurred during the procedure.
The patient had a history of hypertension and fatty liver disease. He had consumed alcohol for more than 30 years, averaging 250-500 ml of white wine per day.
Coronary angiography showed proximal complete occlusion of the anterior descending branch, complete occlusion of the right coronary artery opening, and 99% stenosis of the proximal circumflex coronary artery. The patient was transferred to the intensive care unit (ICU) after intra-aortic balloon pumping (IABP). The patient was admitted with a distended abdomen and a bladder pressure of 25 cmH2O to maintain circulation and treat myocardial infarction. The acid suppression with proton pump inhibitors was administered to the patient due to approximately 500 ml of coffee-like fluid draining from the gastric tube. The following biochemical index levels were present at admission: alanine aminotransferase (ALT) [143 U/l (0-40 U/l)], aspartate aminotransferase (AST) [917 U/l (0-40 U/l)], gamma-glutamyl transferase (GGT) [56 U/l (3-50 U/l)], alkaline phosphatase (ALP) [41 U/l (50-140 U/l)], total bilirubin (TBI) [7.4 mumol/l (3.4-17.1 mumol/l)], with the negative results of hepatitis A virus (HAV; IgG and IgM anti-HAV), hepatitis C virus (HCV; IgG and IgM anti-HCV), hepatitis E virus (HEV; IgG and IgM anti-HEV), hepatitis D virus (HDV; IgG and IgM anti-HDV), and hepatitis B surface antigen (HBsAg). Bedside ultrasound showed normal gallbladder size and wall and no dilatation of the intra- and extra-hepatic bile ducts. Elevated ALT and AST on admission was considered as liver injury due to ischemia and hypoxia. Liver perfusion pressure was maintained after admission. Some index values determined on September 7, 2021 were as follows: TBI-75.9 mumol/l, direct bilirubin (DBILI)-43.6 mumol/l (0-6.8 mumol/l), and indirect bilirubin (IBIL)-32.3 mumol/l (1.7-10.2 mumol/l). There was no significant change in the gallbladder on bedside ultrasound. We considered that the bilirubin might be elevated due to biliary stasis, so we opened enteral nutrition and added hepatoprotective medication. The following index levels were present on September 8, 2021: GGT-52 U/l, ALP-4 U/l, ALT-784 U/l, AST-2076 U/l, TBIL-94 mumol/l, DBILI-58.2 mumol/l, and IBIL-35.8 mumol/l, with normal ranges of prothrombin time (PT) and international normalized ratio (INR). After that, the TBI value fluctuated around 100 mumol/l, GGT and ALP levels remained normal, and daily ultrasound of the gallbladder revealed no significant abnormality, with the intra-abdominal pressure ranging from 20 to 30 mmH2O. The patient had no bowel movement. Therefore, he received continuous gastrointestinal (GI) decompression and intermittent enemas. The patient was changed to veno-arterial-venous (VAV)-ECMO on September 10, 2021(Right femoral artery, right femoral vein, right internal jugular vein), due to inadequate oxygenation, and his circulation and oxygenation functions gradually improved. The TBI level rose to 152.4 mumol/l on September 11, 2021 (Figure 1). We screened the portal vein and gallbladder ultrasounds and found an open portal vein with smooth flow and biliary stasis in the gallbladder. The patient did not wake up even after stopping sedative drugs. Abdominal CT (Figure 2) was performed with the assistance of ECMO and an intraaortic balloon pump (IABP). The multi-disciplinary teams (MDT) thought that the patient's current liver injury and long-term hypoperfusion were caused by long-term alcohol consumption and alcoholic liver disease. The current hyperbilirubinemia should be considered intrahepatic cholestasis caused by long-term fasting and drug use. The gastroenterologist did not recommend endoscopic retrograde cholangiopancreatography because he thought that the patient had no signs of biliary obstruction or hemolytic jaundice. The patient showed high intra-abdominal pressure and poor intestinal motility. Therefore, we performed the cholecystectomy with ECMO support, and the pathologic finding suggested gallbladder gangrene (Figure 3). The patient's cardiac function recovered poorly after surgery, and he died on the 16th day of ECMO treatment.