Clinical DSA 4: Hepatobiliary - Acute Hepatitis and Liver Failure Flashcards
Etiologies of acute hepatitis
*Infectious (mostly viral)
*Drugs/toxins
Budd chiari
Shock
Which diagnosis?
Acute onset (within 8 weeks of insult)
N/V, jaundice, elevated AST/ALT that eventually falls
Rapidly rising bilirubin
Rapidly shrinking liver, hepatic encephalopathy (elevated ammonia)
Coagulation abnormalities (INR>1.5)
Usually due to APAP toxicity
Acute (fulminant) liver failure
[ALF]
ALF diagnostics
Rapidly rising bilirubin and prolongation of PT/INR even as AST/ALT rise and fall
Tool used to assess risk of hepatotoxicity after ingestion of APAP
Rumack-Matthew Nomogram
Plots APAP concentration vs time after ingestion
What AST/ALT is diagnostic of APAP toxicity?
AST/ALT > 5000
Treatment/Management of acute liver failure
Consider transfer to transplant center
N-acetylcysteine (NAC) in APAP overdose per Rumack-Matthew nomogram
Eitiologies of ALF
- APAP*
- Idiosyncratic drug rxn
- Viral hep, poison mushrooms, shock, budd-chiari, fatty liver of pregnancy
Complications of ALF
- Cerebral edema and death*
- Multi organ failure and death if untreated
- mortality rate >80% if in deep coma
Which hepatitis virus?
Acute only, contaminated water or shellfish
N/V, Jaundice, RUQ pain
Dark urine, acholic stools
Aversion to smoking
Elevated AST/ALT, bilirubin, ALP (hepatocellular and cholestatic)
HAV
Which hepatitis virus?
Acute (90% recover) or chronic (10%)
Transfer via blood, sex or perinatal
Variable clinical picture, N/V, Jaundice, RUQ pain
Polyarteritis nodosa, glomerularnephritis, serum sickness
Elevated AST/ALT, PT/INR (hepatocellular)
Bilirubin, ALP not exceedingly high
HBV
Which hepatitis virus?
Acute or chronic
Transmitted through blood
N/V, Jaundice, RUQ pain
Requires HBV coinfection
HDV
Which hepatitis virus?
Mostly chronic
Transmitted thru blood (transfusions, IVDU, fisticuffs, needles)
Clinically mild and asymptomatic until cirrhosis
Waxing and waning AST/ALT
Occasionally may have Abs in serum w/o RNA meaning recovery from previous infection
HCV
Which hepatitis virus?
Acute, Chronic in immunocompromised
Transmission is fecal-oral via waterborne epidemics or undercooked organ meat (spread by swine)
N/V, Jaundice, RUQ pain
Aversion to smoking
Fulminant can happen in pregnant patients*
Transplant pts treated w/ tacrolimus progress to chronic*
HEV
HAV vaccine available?
Yeah!
its self limited tho
HBV vaccine available?
Yeah!
HDV vaccine available?
Not directly. Vaccinate against HBV because it requires coinfection
HCV vaccine available?
NOPE!!!
Patients w/ chronic liver disease should be vaccinated against HAV and HBV
HEV vaccine available?
NOPE!!!
its self limited tho
Complications of HBV
Chronic HBV carries substantial risk for cirrhosis and HCC
especially with HDV superinfection
Complications of HCV
Cirrhosis, HCC, HIV coinfection
mixed cryoglobulinemia
HCV prevention and screening
Screen boomers
Screen everyone over 18 at least once
Drug induced liver injury (DILI) and drug induced hepatitis eitiology
Dose dependent drug toxicity (APAP most common)
Idiosyncratic
DILI treatment/management
Withdraw suspected agent, most will resolve quickly after
What diagnosis?
RUQ pain, nausea, malaise, pruritis, jaundice after ingestion of drug
Mimics acute cholecystitis
May present with systemic hypersensitivity (eosinophilia)
DILI or drug induced hepatitis
Complication is fulminant liver failure
Treatment for APAP overdose
n-acetylcysteine (NAC)
ICU and transplant center
APAP overdose stage?
N/V, abdominal pain, sweating, general discomfort, pale
Normal LFTs
Stage 1
days 0-1
APAP overdose stage?
Liver injury develops
RUQ pain
Rise in LFTs (ALT, AST, ALP bili)
Stage 2
days 1-3
APAP overdose stage?
Hepatotoxicity peaks Rapid and severe hepatic failure Encephalopathy and hypoglycemia Glucose, lactate and phosphate abnormalities Coma and death
Stage 3
3-5 days
APAP overdose stage?
Recovery stage for those who survive
Stage 4
days 5-8
What diagnosis?
Occlusion of hepatic vein of IVC Hypercoagulable state (IBD, OCPs, pregnancy, polycythemia vera)* Nutmeg liver (centrilobular congestion)* Hepatomegaly RUQ pain and tenderness
Budd-Chiari syndrome
occlusion of flow to hepatic vein or IVC
Diagnosic test for Budd-Chiari
Contrast enhanced color ultrasound (CEUS)
Pulsed-Doppler ultrasound
Shows prominent caudate liver lobe
