Here is the home page of The Clinical Problem Solvers.
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.]
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.
01:58one thing that i sometimes struggle with02:00an internist is the overlap between02:03alcohol use disorder and liver disease02:05do you have any pearls about if you have02:07concerned that someone may be developing02:09cirrhosis but it’s also02:12there is significant alcohol use that02:14could also be contributing to the02:15thrombocytopenia is there any way to02:17differentiate that02:20so you ask a very good question02:23and at the point that a patient is02:25developing some degree of bone marrow02:27suppression from alcohol use disorder02:29they’re already at an increased risk of02:32harm and if it’s important if that02:35patient needs extra reasons to be02:38worried about their health or motivated02:40about a change raising the possibility02:42of liver disease even when uncertain is02:45probably a useful tool and when you see02:48a patient like that i’m more than happy02:51to help sort things out either through02:54monitoring to see what happens after a02:56trial of substance use disorder therapy02:59doing non-invasive or liver biopsy03:02testing to figure out what’s going on03:03inside their liver and helping you03:06sort out exactly what your patient’s03:08stage might be03:12awesome well without further ado
03:26 [The internist is calling the hepatologist for]subspecialty care so the consult03:28question is going to be03:30severe acute liver injury03:33um so you’re going to be consulted about03:37lft rise with ast and alt in the03:41thousands as well as t-belly elevation03:45so just a little bit of background03:48story and then i’ll let you um ask kind03:52of some follow-up questions um and some03:54identifying details of this case have03:56been changed to protect identity03:59um so this is a 68 year old female with04:03a past medical history of hypertension04:05and hyperlipidemia04:07she is from mexico um but is visiting04:10her daughter um04:12in the east and um she04:16on presentation the daughter noticed04:18that um her eyes were yellow and she had04:20yellowing of the skin um she’s also been04:23very like04:24fatigued as well for the past 10 days um04:29they had not seen each other for the04:31past two weeks kind of other relevance04:34situations where there was and one day04:37of diarrhea04:39about a week prior to coming to the04:41hospital and then also some shortness of04:44breath with walking that was difficult04:46to quantify and have some diffuse04:49myalgias04:51but no04:52fevers or chills04:55she says she has been taking04:56acetaminophen um for04:59her chronic foot pain while in mexico um05:03but was unsure exactly how much she was05:05taking um05:07and then no recent travel05:11or nonstick contacts05:13no significant05:14alcohol use05:16um so at this point i know that you05:18don’t have all the exact laboratory data05:20but just kind of hearing this background05:22are there any specific05:24um questions or further evaluation have05:27you heard this consult question on the05:29phone that you would want to know about05:31right away
05:34um so i would say the i the first thing05:37that has set the way that i think about05:40this is i’ve been told this person has05:42severe acute liver injury and they have05:44jaundice and then you’ve gone on to05:46elaborate on a variety of other symptoms05:49that speak to a systemic process that05:52feels like it’s raising the possibility05:55of an infection or a toxic insult but05:59from behind the veil of ignorance just06:01going based on06:03epidemiology06:05alone there are really a very06:08limited number of things that can cause06:11a severe acute liver injury number one06:15will always be no matter which practice06:18setting you’re working in ischemic06:20hepatitis which typically happens in the06:23context of heart failure and i would06:26like to know you know what she what what06:29she looks like does she have cool clammy06:33extremities06:34then number two is going to be drug06:37induced liver injury you’ve piqued my06:40interest hearing about acetaminophen but06:43i want to know what else she is taking06:46and i’m looking for other sources of06:48acetaminophen i’ll oftentimes you’ll06:51hear people when they’re feeling bad06:52take both tylenol nyquil percocet all06:56things that would have acetaminophen in06:59them but i want to know the whole list07:01including the random supplements they07:04might be taking and i don’t remember07:06what which ones cause liver injury other07:09than like the common ones like07:11anti-epileptics and antibiotics so as07:13soon as you tell me that whole list i’m07:15plugging them into hepatology google07:18which is livertox.gov07:20and i’m looking to see what the rate of07:22liver injury on each of those might be07:24and then finally like i said07:26i worry about an infectious process the07:29third most common probability07:31possibility first for someone with this07:34kind of history07:35would be something like viral hepatitis07:38hepatitis a07:39potentially even07:41
hepatitis07:43b and rarely you will also see acute07:46hepatitis c so i’d want to know a little07:48bit about about the exposures to that07:51but i will definitely be testing for07:53those things no matter what the history07:56tells me
08:00awesome um just to give a little bit08:02more history and the patient had been