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 Report–Episode 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

Note that Dr. Tapper states that the most common cause of acute liver injury is ischemic hepatitis from heart failure. Dr. Farkas in an IBCC chapter states that there need not be hypotension in this disease. [Personal thought: If ischemic hepatitis from heart failure is a common cause of acute liver injury, perhaps a VExUS exam should be included in the evaluation]

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

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

08:00

awesome um just to give a little bit

08:02

more history and the patient had been