🟤 Approach to Acute Hepatocellular Injury 🟤
The DDx of ↑ AST & ALT out of proportion to ↑ in cholestatic labs is easy for most.
BUT! I think some can't-miss conditions are frequently left out by early learners.
Here's a diagnostic approach that'll prioritize those causes.
The DDx of ↑ AST & ALT out of proportion to ↑ in cholestatic labs is easy for most.
BUT! I think some can't-miss conditions are frequently left out by early learners.
Here's a diagnostic approach that'll prioritize those causes.
Acute hepatocellular injury = 3 P's.
- Plumbing (Biliary & Vascular)
- Pregnancy
- Parenchyma
- Plumbing (Biliary & Vascular)
- Pregnancy
- Parenchyma
1st Pass = Plumbing
🟩 Acute CBD obstruction is commonly forgotten because we think of the late cholestatic labs seen after prolonged obstruction. However, acute ↑ in AST & ALT is actually what we see first, as Alk Phos takes time to synthesize
🟩 Acute CBD obstruction is commonly forgotten because we think of the late cholestatic labs seen after prolonged obstruction. However, acute ↑ in AST & ALT is actually what we see first, as Alk Phos takes time to synthesize
🟥 Regarding vascular etiologies, ischemic hepatitis joins acute choledocholithiasis in the top 3 causes of acute, severe ↑ in AST & ALT
2nd Pass = Pregnancy
🟪 There are 3 can't-miss pregnancy-related diagnoses w/ distinct signatures, but all usually occur in late 2nd to 3rd trimesters
🟪 HELLP Syndrome = MAHA, ↓ platelets, abdominal pain, HTN, & proteinuria
🟪 There are 3 can't-miss pregnancy-related diagnoses w/ distinct signatures, but all usually occur in late 2nd to 3rd trimesters
🟪 HELLP Syndrome = MAHA, ↓ platelets, abdominal pain, HTN, & proteinuria
🟪 Acute Fatty Liver is commonly considered the scariest: can cause acute liver failure (ALF)!
🟪 Intrahepatic Cholestasis is marked by pruritus & ↑ bile acids
🟪 Intrahepatic Cholestasis is marked by pruritus & ↑ bile acids
3rd Pass = Parenchymal etiologies (Toxic, Infectious, Autoimmune)
🟤 Start w/ Toxic etiologies, that way you don't forget to take a good ingestion history (meds, drugs, supplements, "natural" remedies)
🟤 DILI (including acetaminophen) joins the top 3 causes of acute injury
🟤 Start w/ Toxic etiologies, that way you don't forget to take a good ingestion history (meds, drugs, supplements, "natural" remedies)
🟤 DILI (including acetaminophen) joins the top 3 causes of acute injury
🟤 The list of drugs that can cause DILI is huge. Check out LiverTox!
LiverTox: ncbi.nlm.nih.gov
🟤Also, check out @theliverdr for a feed featuring frequent toxic ingestions
LiverTox: ncbi.nlm.nih.gov
🟤Also, check out @theliverdr for a feed featuring frequent toxic ingestions
Next, consider infections:
🟡 Viral hepatitis serologies are frequently a must
🟡 If an extra-hepatic signature is present (eg rash, pneumonia), consider arboinfections & zoonoses
🟡 Consider other viruses if immunocompromised
🟡 Viral hepatitis serologies are frequently a must
🟡 If an extra-hepatic signature is present (eg rash, pneumonia), consider arboinfections & zoonoses
🟡 Consider other viruses if immunocompromised
Finally, enter esoteric land (autoimmune hepatitis comes last):
🔵 Various autoantibodies & presentations, ↑ IgG
🔵 While most have insidious & fluctuating course, up to 25% have acute presentation
🔵 Various autoantibodies & presentations, ↑ IgG
🔵 While most have insidious & fluctuating course, up to 25% have acute presentation
Summary:
🏁 Acute hepatocellular injury DDx frequently misses acute CBD obstruction & pregnancy-related etiologies
🏁 3 P's prioritize can't-miss diagnoses
🏁 Don't forget to take a good oral intake history
🏁 Acute hepatocellular injury DDx frequently misses acute CBD obstruction & pregnancy-related etiologies
🏁 3 P's prioritize can't-miss diagnoses
🏁 Don't forget to take a good oral intake history
References:
1) casereports.bmj.com
2) ncbi.nlm.nih.gov
3) journals.lww.com
4)
5)
6) #H116577307" target="_blank" rel="noopener" onclick="event.stopPropagation()">uptodate.com
7) #H632891544" target="_blank" rel="noopener" onclick="event.stopPropagation()">uptodate.com
8) uptodate.com
9) path.upmc.edu
1) casereports.bmj.com
2) ncbi.nlm.nih.gov
3) journals.lww.com
4)
5)
6) #H116577307" target="_blank" rel="noopener" onclick="event.stopPropagation()">uptodate.com
7) #H632891544" target="_blank" rel="noopener" onclick="event.stopPropagation()">uptodate.com
8) uptodate.com
9) path.upmc.edu
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