Clinical DSA 4: Hepatobiliary - Acute Hepatitis and Liver Failure

Question 1

Etiologies of acute hepatitis

Answer 1

*Infectious (mostly viral)
*Drugs/toxins
Budd chiari
Shock

Question 2

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

Answer 2

Acute (fulminant) liver failure

[ALF]

Question 3

ALF diagnostics

Answer 3

Rapidly rising bilirubin and prolongation of PT/INR even as AST/ALT rise and fall

Question 4

Tool used to assess risk of hepatotoxicity after ingestion of APAP

Answer 4

Rumack-Matthew Nomogram

Plots APAP concentration vs time after ingestion

Question 5

What AST/ALT is diagnostic of APAP toxicity?

Answer 5

AST/ALT > 5000

Question 6

Treatment/Management of acute liver failure

Answer 6

Consider transfer to transplant center

N-acetylcysteine (NAC) in APAP overdose per Rumack-Matthew nomogram

Question 7

Eitiologies of ALF

Answer 7

1. APAP*
2. Idiosyncratic drug rxn
3. Viral hep, poison mushrooms, shock, budd-chiari, fatty liver of pregnancy

Question 8

Complications of ALF

Answer 8

1. Cerebral edema and death*
2. Multi organ failure and death if untreated
3. mortality rate >80% if in deep coma

Question 9

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)

Answer 9

HAV

Question 10

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

Answer 10

HBV

Question 11

Which hepatitis virus?

Acute or chronic
Transmitted through blood
N/V, Jaundice, RUQ pain
Requires HBV coinfection

Answer 11

HDV

Question 12

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

Answer 12

HCV

Question 13

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*

Answer 13

HEV

Question 14

HAV vaccine available?

Answer 14

Yeah!

its self limited tho

Question 15

HBV vaccine available?

Answer 15

Yeah!

Question 16

HDV vaccine available?

Answer 16

Not directly. Vaccinate against HBV because it requires coinfection

Question 17

HCV vaccine available?

Answer 17

NOPE!!!

Patients w/ chronic liver disease should be vaccinated against HAV and HBV

Question 18

HEV vaccine available?

Answer 18

NOPE!!!

its self limited tho

Question 19

Complications of HBV

Answer 19

Chronic HBV carries substantial risk for cirrhosis and HCC

especially with HDV superinfection

Question 20

Complications of HCV

Answer 20

Cirrhosis, HCC, HIV coinfection

mixed cryoglobulinemia

Question 21

HCV prevention and screening

Answer 21

Screen boomers

Screen everyone over 18 at least once

Question 22

Drug induced liver injury (DILI) and drug induced hepatitis eitiology

Answer 22

Dose dependent drug toxicity (APAP most common)

Idiosyncratic

Question 23

DILI treatment/management

Answer 23

Withdraw suspected agent, most will resolve quickly after

Question 24

What diagnosis?

RUQ pain, nausea, malaise, pruritis, jaundice after ingestion of drug
Mimics acute cholecystitis
May present with systemic hypersensitivity (eosinophilia)

Answer 24

DILI or drug induced hepatitis

Complication is fulminant liver failure

Question 25

Treatment for APAP overdose

Answer 25

n-acetylcysteine (NAC) ICU and transplant center

Question 26

APAP overdose stage? N/V, abdominal pain, sweating, general discomfort, pale Normal LFTs

Answer 26

Stage 1 | days 0-1

Question 27

APAP overdose stage? Liver injury develops RUQ pain Rise in LFTs (ALT, AST, ALP bili)

Answer 27

Stage 2 | days 1-3

Question 28

APAP overdose stage? ``` Hepatotoxicity peaks Rapid and severe hepatic failure Encephalopathy and hypoglycemia Glucose, lactate and phosphate abnormalities Coma and death ```

Answer 28

Stage 3 | 3-5 days

Question 29

APAP overdose stage? Recovery stage for those who survive

Answer 29

Stage 4 | days 5-8

Question 30

What diagnosis? ``` Occlusion of hepatic vein of IVC Hypercoagulable state (IBD, OCPs, pregnancy, polycythemia vera)* Nutmeg liver (centrilobular congestion)* Hepatomegaly RUQ pain and tenderness ```

Answer 30

Budd-Chiari syndrome | occlusion of flow to hepatic vein or IVC

Question 31

Diagnosic test for Budd-Chiari

Answer 31

Contrast enhanced color ultrasound (CEUS) Pulsed-Doppler ultrasound Shows prominent caudate liver lobe