Week 15 - Jaundice (Hepatitis And Paracetamol OD)

Question 1

What is the route of transmission for Hep A, B, C , D and E?

Answer 1

Hep A = faecal-oral
Hep B = blood/bodily fluids
Hep C = blood/bodily fluids
Hep D = blood/bodily fluids
Hep E = faecal-oral

Question 2

Are Hep A, B, C , D and E acute or chronic infections ?

Answer 2

Hep A = acute
Hep B = acute and chronic
Hep C = acute and chronic
Hep D = acute and chronic
Hep E = chronic

Question 3

What are the 4 main functions of the liver ?

Answer 3

• produce clotting factors
• store excess glucose as glycogen
• metabolism (carbs, fats, proteins)
• destroy harmful substances (drugs, bacteria, cellular debris etc)

Question 4

What are the 3 most common causes of liver cirrhosis in the western world ?

Answer 4

• alcohol-related liver disease
• non-alcoholic fatty liver disease
• chronic viral hepatitis

Question 5

What is important to know regarding admission of a patient who has taken a paracetamol overdose ?

Answer 5

• number of tablets taken ?
• if they were all taken at once or staggered ?
• when was the overdose ?
• was it only paracetamol ?
• do they take any other regular medications ?

Question 6

What examination findings indicate development of hepatotoxicity ?

Answer 6

• confusion due to hepatic encephalopathy
• flapping hand tremor (liver asterixis)
• jaundice in skin or eyes
• bruised skin
• bleeding gums
• tenderness in RUQ
• hepatomegaly

Question 7

What treatment is given in a paracetamol overdose ? What is its MOA ?

Answer 7

N-Acetylcysteine (IV)

Acts as a Glutathione donor, preventing toxic buildup of NAPQI

Question 8

When do you administer N-Acetylcysteine ?

Answer 8

In paracetamol overdose patients when….

• plasma-paracetamol conc is above the line on the treatment graph
• they present 8-24hrs after ingestion of >150mg/kg
• they present >24hrs after ingestion and have clear jaundice or if they have hepatic tenderness, raised ALT above upper limit of normal, an INR >1.3 or a paracetamol conc is detectable

Question 9

What dose of paracetamol is considered high risk of toxicity in an overdose ?

Answer 9

More than 150 mg/kg

75-150 mg/kg is rarely toxic, and less than 75 is very unlikely

Question 10

What does ‘therapeutic excess’ of paracetamol mean ?

Answer 10

When the dose of paracetamol ingested is potentially toxic, but with no intent of self harm

e.g in order to try treat pain etc

Question 11

When should someone be referred to a hospital, regarding potential paracetamol overdose ?

Answer 11

• if symptomatic (jaundice etc)
• if ingested 75 mg/kg or more within 24hrs
• if ingested more than listed dose, but less than 75 mg/kg/24hrs on both the preceding 2+ days

Question 12

What is considered a ‘staggered dose’ when referring to a paracetamol overdose ?

Answer 12

Staggered dose = a potentially toxic dose taken over the span of more than 1hr with the intention of self harm

Question 13

What is the treatment for patients who have had a paracetamol overdose via a staggered dose timeframe ?

Answer 13

Immediately treat them with acetylcysteine

Question 14

When is a liver transplant indicated following a paracetamol overdose ?

Answer 14

• arterial pH <7.3 or lactate >3 after fluid resus, OR
• if all of the following occur in a 24hr period…
  — creatinine >300 micromol/L
  — PT >100secs (INR >6.6)
  — grade 3/4 encephalopathy

Question 15

When does toxicity usually peak after a paracetamol overdose ?

Answer 15

48-72 hrs after ingestion

Question 16

What investigations would you request in a patient with a paracetamol overdose ?

Answer 16

• ABGs
• LFTs
• U+Es
• clotting (PT, INR etc)
• blood glucose
• paracetamol levels

urine dipstick, FBC, chest X-ray etc is not necessary

Question 17

Do you treat a patient after a paracetamol overdose if you don’t know the dose ingested or time of ingestion ?

Answer 17

Yes! Always best to treat in this scenario

Question 18

What bedside signs would indicate a patient is developing liver failure ?

Answer 18

• spontaneous bruising/bleeding at venepuncture sites (progressive coagulopathy)
• reduced urine output *indicates possible AKI
• hypoglycaemia indicates hepatic necrosis
• metabolic acidosis despite hydration
• hypotension despite hydration
• encephalopathy with agitation rather than drowsiness

Question 19

Acute liver failure is rare but can be seen in cases of …

Answer 19

• severe viral hepatitis (E is most common, but A and B too)
• acute injury to the liver (especially Budd Chiari syndrome)
• autoimmune hepititis
• direct exposure to toxins e.g amanita mushroom poisoning