Virtual Morning Report-Episode 569- January 26 – Acute liver injury With A Link To Diagnostic Schemas For Liver Disease

Here is the home page of The Clinical Problem Solvers.

Here is The Clinical Problem Solvers’ page listing of Diagnostic Schemas for liver disease

Here is the link to the home page for Virtual Morning Report [From this link you can directly access all 572 episodes].

Virtual Morning ReportEpisode 569 – Virtual Morning Report – January 26 – Acute liver injury [Watch on the Clinical Problem Solvers What follows is from the above resource.]

Case presenter – Ann Marie

Case overview & teaching points – Here

Download the above PDF

Download the above PDF here.

In this post I link to and excerpt from The YouTube Clinical Problem Solvers‘ “January 26, 2022 Hepatology VMR with Dr. Elliot Tapper – acute liver failure” [Link is to the video on YouTube]

By watching the video on YouTube, you can follow along in the autogenerated transcript which is usually adequate.

What follows is from the autogenerated transcript.

01:58
one thing that i sometimes struggle with
02:00
an internist is the overlap between
02:03
alcohol use disorder and liver disease
02:05
do you have any pearls about if you have
02:07
concerned that someone may be developing
02:09
cirrhosis but it’s also
02:12
there is significant alcohol use that
02:14
could also be contributing to the
02:15
thrombocytopenia is there any way to
02:17
differentiate that
02:20
so you ask a very good question
02:23
and at the point that a patient is
02:25
developing some degree of bone marrow
02:27
suppression from alcohol use disorder
02:29
they’re already at an increased risk of
02:32
harm and if it’s important if that
02:35
patient needs extra reasons to be
02:38
worried about their health or motivated
02:40
about a change raising the possibility
02:42
of liver disease even when uncertain is
02:45
probably a useful tool and when you see
02:48
a patient like that i’m more than happy
02:51
to help sort things out either through
02:54
monitoring to see what happens after a
02:56
trial of substance use disorder therapy
02:59
doing non-invasive or liver biopsy
03:02
testing to figure out what’s going on
03:03
inside their liver and helping you
03:06
sort out exactly what your patient’s
03:08
stage might be
03:12
awesome well without further ado
03:26 [The internist is calling the hepatologist for]
subspecialty care so the consult
03:28
question is going to be
03:30
severe acute liver injury
03:33
um so you’re going to be consulted about
03:37
lft rise with ast and alt in the
03:41
thousands as well as t-belly elevation
03:45
so just a little bit of background
03:48
story and then i’ll let you um ask kind
03:52
of some follow-up questions um and some
03:54
identifying details of this case have
03:56
been changed to protect identity
03:59
um so this is a 68 year old female with
04:03
a past medical history of hypertension
04:05
and hyperlipidemia
04:07
she is from mexico um but is visiting
04:10
her daughter um
04:12
in the east and um she
04:16
on presentation the daughter noticed
04:18
that um her eyes were yellow and she had
04:20
yellowing of the skin um she’s also been
04:23
very like
04:24
fatigued as well for the past 10 days um
04:29
they had not seen each other for the
04:31
past two weeks kind of other relevance
04:34
situations where there was and one day
04:37
of diarrhea
04:39
about a week prior to coming to the
04:41
hospital and then also some shortness of
04:44
breath with walking that was difficult
04:46
to quantify and have some diffuse
04:49
myalgias
04:51
but no
04:52
fevers or chills
04:55
she says she has been taking
04:56
acetaminophen um for
04:59
her chronic foot pain while in mexico um
05:03
but was unsure exactly how much she was
05:05
taking um
05:07
and then no recent travel
05:11
or nonstick contacts
05:13
no significant
05:14
alcohol use
05:16
um so at this point i know that you
05:18
don’t have all the exact laboratory data
05:20
but just kind of hearing this background
05:22
are there any specific
05:24
um questions or further evaluation have
05:27
you heard this consult question on the
05:29
phone that you would want to know about
05:31
right away
So Dr Tapper begins his analysis:
05:34
um so i would say the i the first thing
05:37
that has set the way that i think about
05:40
this is i’ve been told this person has
05:42
severe acute liver injury and they have
05:44
jaundice and then you’ve gone on to
05:46
elaborate on a variety of other symptoms
05:49
that speak to a systemic process that
05:52
feels like it’s raising the possibility
05:55
of an infection or a toxic insult but
05:59
from behind the veil of ignorance just
06:01
going based on
06:03
epidemiology
06:05
alone there are really a very
06:08
limited number of things that can cause
06:11
a severe acute liver injury number one
06:15
will always be no matter which practice
06:18
setting you’re working in ischemic
06:20
hepatitis which typically happens in the
06:23
context of heart failure and i would
06:26
like to know you know what she what what
06:29
she looks like does she have cool clammy
06:33
extremities
06:34
then number two is going to be drug
06:37
induced liver injury you’ve piqued my
06:40
interest hearing about acetaminophen but
06:43
i want to know what else she is taking
06:46
and i’m looking for other sources of
06:48
acetaminophen i’ll oftentimes you’ll
06:51
hear people when they’re feeling bad
06:52
take both tylenol nyquil percocet all
06:56
things that would have acetaminophen in
06:59
them but i want to know the whole list
07:01
including the random supplements they
07:04
might be taking and i don’t remember
07:06
what which ones cause liver injury other
07:09
than like the common ones like
07:11
anti-epileptics and antibiotics so as
07:13
soon as you tell me that whole list i’m
07:15
plugging them into hepatology google
07:18
which is livertox.gov
07:20
and i’m looking to see what the rate of
07:22
liver injury on each of those might be
07:24
and then finally like i said
07:26
i worry about an infectious process the
07:29
third most common probability
07:31
possibility first for someone with this
07:34
kind of history
07:35
would be something like viral hepatitis
07:38
hepatitis a
07:39
potentially even
07:41

hepatitis

07:43
b and rarely you will also see acute
07:46
hepatitis c so i’d want to know a little
07:48
bit about about the exposures to that
07:51
but i will definitely be testing for
07:53
those things no matter what the history
07:56
tells me
Next the case presenter gives us more information. Stat here:
08:00
awesome um just to give a little bit
08:02
more history and the patient had been
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