Adult Hepatic Infarction for Internists: A Practical Diagnostic and Management Pathway to Avoid Misdiagnosis, Unnecessary Drainage, and Delayed Vascular Recognition.

Introduction: Hepatic infarction is an uncommon but clinically important cause of focal ischemic liver injury. In internal medicine, it usually emerges in acutely ill or complex hospitalized adults with sepsis, shock, malignancy, thrombosis, vasculitis, transplantation, or recent hepatobiliary or interventional procedures who develop a new focal hepatic lesion and abnormal liver tests. Aims: This review aims to provide internists with a practical diagnostic and management pathway for recognizing hepatic infarction, distinguishing it from abscess and malignancy, selecting appropriate imaging, identifying vascular complications, and avoiding unnecessary biopsy or drainage when conservative management is safer. Methods: We performed a structured narrative review of adult hepatic infarction and related ischemic liver entities using targeted searches in PubMed/MEDLINE and Scopus. The search strategy, screening process, and evidence limitations are reported explicitly. Because the available evidence is dominated by case reports, small series, radiology reviews, and guidance on related vascular liver diseases, the synthesis is qualitative and the proposed pathway is conceptual rather than prospectively validated. Results: Hepatic infarction is most often recognized when systemic hypoperfusion, splanchnic vasoconstriction, microvascular dysfunction, or local macrovascular compromise coexist. Multiphasic computed tomography (CT) is usually the first-line acute-care modality, while MRI, contrast-enhanced ultrasound, Doppler ultrasound, CT angiography, or vascular imaging should be selected according to diagnostic uncertainty and suspected arterial or portal venous complications. The main diagnostic pitfalls are misclassification as abscess, malignancy, hematoma, or postoperative collection. Conclusions: In the appropriate clinical context, a wedge-shaped or geographic non-enhancing hepatic lesion should trigger vascular-ischemic reasoning before being labeled as abscess or tumor. The proposed internist-led pathway is intended as a pragmatic conceptual framework for diagnostic reasoning and multidisciplinary communication, not as a validated guideline or evidence-based algorithm.