Week 15 - Case One and Two Flashcards
in paracetamol, what is associated with higher risk of hepatotoxicity
delayed presentation
what is it important to assess for in paracetamol overdose for hepatotoxicity
- Confusion due to hepatic encephalopathy
- Liver asterixis (flapping tremor)
- Yellow skin or sclera due to jaundice
- Bruising of the skin or bleeding of the gums or from anywhere due to clotting derangement
- Tenderness in the right upper quadrant due to liver inflammation
- Hepatomegaly
in patients who present within 24 hours of an overdose and biochemical tests suggest ALI, even though the plasma paracetamol conc. is below the treatment line on the graph, what should be started
acetylcysteine
what does a staggered overdose involve
A staggered overdose involves ingestion of a potentially toxic dose of paracetamol over more than 1 hour, with the possible intention of causing self-harm. All patients who have taken a staggered overdose should be referred to hospital for medical assessment. The MHRA advises that all patients who have ingested a staggered overdose should be treated with acetylcysteine without delay.
what is the criteria for liver transplant following paracetamol overdose
King’s college criteria: Liver transplant in paracetamol induced acute liver failure is indicated if:
Arterial pH <7.3 or arterial lactate >3.0 after adequate fluid resuscitation,
OR
If all of the three following occur in 24-hour period:
Creatinine >300micromol/l
PT >100 seconds (INR >6.5)
Grade III/IV encephalopathy
when does toxicity peak in paracetamol overdose
48-72 hours after ingestion
what can be an early indictor of acute liver failure
acidosis
what is the most concerning initial blood result in paracetamol overdose
Prothrombin Time (PT)
The biggest concern in the blood tests given is that he has developed a degree of coagulopathy indicating there is some degree of liver function impairment.
what is the usual management plan alongside acetylcysteine in paracetamol overdose
Catheterisation and hourly recording of urine output
Hourly capillary blood glucose recording
10mg of vitamin K IV
Repeat coagulation panel in six hours
why should you avoid giving fresh frozen plasma to correct the prothrombin time in paracetamol overdose
as this makes it impossible to interpret the prothrombin time and use it to guide management over the next few hours
what clinical signs and bedside tests would you look for as an indication that the patient is developing liver failure
- Spontaneous bruising or bleeding at venepuncture sites as a sign of progressive coagulopathy
- Reduced urine output indicating possible acute kidney injury
- Hypoglycaemia (indicated hepatic necrosis)
- Metabolic acidosis despite hydration
- Hypotension despite hydration
- Encephalopathy, which in this case may present with agitation, confusion or aggression rather than drowsiness as seen in chronic liver disease
what is acute liver failure defined as
liver injury with the presence of hepatic encephalopathy in a patient without related pre-existing liver disease.
what does an isolated raised ALT level suggest
suggests a hepatitic type problem
inflammation within the liver
which two components assess the actual function of the liver
bilirubin and albumin
what are the most common causes of inflammatory liver processes
- Fatty liver related to alcohol
- A viral infection
- Non-alcohol related fatty liver (usually associated with metabolic syndrome)
- Autoimmune liver disease
what should be checked for haemochromatosis
- Ferritin should be checked for haemochromatosis.
what is haemochromatosis
Haemachromatosis is an autosomal recessive genetic condition affecting the HFE gene which causes deficiency of the iron-regulatory hormone hepcidin. Symptoms occur as a result of accumulation of iron in tissues. Early symptoms include fatigue, weakness, arthropathy, abdominal pain, erectile dysfunction and cardiac issues (arrhythmia or cardiomyopathy). Late symptoms include: bronzing of the skin, hepatomegaly / cirrhosis of the liver and mood / memory disturbance.
what is the mainstay of treatment for haemochromatosis
phlebotomy to lower iron levels in the blood
A 24-year-old female presents 6 hours after an acute overdose of paracetamol. She weighs 61kg and took 12 x 500mg tablets within 10 minutes. She has no significant past medical history and reports feeling mildly nauseated but otherwise well. Her serum paracetamol levels are 24 at 6 hours and liver function / INR tests all return within normal range. Is treatment indicated?
No
.
The patient is otherwise well, took an acute overdose and paracetamol levels are below treatment line. Therefore, treatment with N-acetylcysteine is not indicated.
A 29-year-old female is being monitored on an inpatient ward following an overdose of 24g of paracetamol. She is alert and orientated when you take bloods from her. When the bloods return, her ALT is 1930, Creatinine 196, INR 1.9. You take a venous blood gas which shows a pH of 7.36.
Does the patient meet criteria for consideration of liver transplant?
No
The King’s College criteria: liver transplant in paracetamol induced acute liver failure is indicated if:
Arterial pH <7.3 or arterial lactate >3.0 after adequate fluid resuscitation
OR
If all of the three following occur in 24-hour period
- Creatinine >300micromol/l
- PT >100 seconds (INR >6.5)
- Grade III/IV encephalopathy
Which of the following are risk factors for hepatitis C?
IV drug use
Tattoos and piercings
Sexual contact
Blood transfusion prior to 1992
Which of the following are potential complications of hepatitis C?
Hepatocellular carcinoma
Sjogren’s syndrome
Skin complications e.g., porphyria cutanea tarda
Liver cirrhosis
What counselling should be given to a patient diagnosed with hepatitis C?
Abstain from alcohol
Avoid sharing razors with others
Aim for ideal body weight
Ensure you are fully vaccinated against other strains of hepatitis
what is haemochromatosis
autosomal recessive genetic condition resulting in iron overload
it is an iron storage disorder
what is the gene involved in haemochromatosis
The human haemochromatosis protein (HFE) gene is located on chromosome 6. The majority of cases of haemochromatosis relate to C282Y mutations in this gene. Mutations are required in both copies of the gene (homozygous) since it is an autosomal recessive condition. This gene is important in regulating iron metabolism.
when does haemochromatosis usually present
after age 40 when the iron overload becomes symptomatic
why does it present later in females
due to mentruation acting to eliminate iron from the body regularly
what does haemochromatosis present with
Chronic tiredness
Joint pain
Pigmentation (bronze skin)
Testicular atrophy
Erectile dysfunction
Amenorrhoea (absence of periods in women)
Cognitive symptoms (memory and mood disturbance)
Hepatomegaly
what is the initial investigation for haemochromatosis
serum ferritin
what are the causes of a raised ferritin
Haemochromatosis
Infections (it is an acute phase reactant)
Chronic alcohol consumption
Non-alcoholic fatty liver disease
Hepatitis C
Cancer
what helps to distinguish between high ferritin caused by iron overload and other causes
transferrin saturation
iron overload (transferrin saturation is high) and other causes (transferrin saturation is normal).
what should be used to establish the iron concentration in the liver
Liver biopsy with Perl’s stain can be used to establish the iron concentration in the liver. Genetic testing means that a liver biopsy is not usually necessary for establishing a diagnosis. It may help stage the fibrosis and exclude other liver pathology.
what are the complications associated with haemochromatosis
Secondary diabetes (iron affects the functioning of the pancreas)
Liver cirrhosis
Endocrine and sexual problems (hypogonadism, erectile dysfunction, amenorrhea and reduced fertility)
Cardiomyopathy (iron deposits in the heart)
Hepatocellular carcinoma
Hypothyroidism (iron deposits in the thyroid)
Chondrocalcinosis (calcium pyrophosphate deposits in joints) causes arthritis
what is the management of Haemochromatosis
Venesection (regularly removing blood to remove excess iron – initially weekly)
Monitoring serum ferritin
Monitoring and treating complications
