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Why is your pt's ALT (or AST) >1000?
A #livertwitter #tweetorial
Take-homes:
1. Top 3 causes of acute liver injury
2. I always say it's ischemic hepatitis; 50% of the time, I'm right every time
Brought to u by:
@tonybreu et al. What causes severe ALI?
cghjournal.org/article/S1542-…
A #livertwitter #tweetorial
Take-homes:
1. Top 3 causes of acute liver injury
2. I always say it's ischemic hepatitis; 50% of the time, I'm right every time
Brought to u by:
@tonybreu et al. What causes severe ALI?
cghjournal.org/article/S1542-…
The liver is awesome.
Yet its vocabulary is ... limited.
We can all tell when it is upset - high ALT, AST.
But that could mean anything!
So what's your specific patient's specific reason for high ALT?
Yet its vocabulary is ... limited.
We can all tell when it is upset - high ALT, AST.
But that could mean anything!
So what's your specific patient's specific reason for high ALT?
First - a poll:
What's the most common cause of severe acute liver injury
(ALT or AST > 10xULN)?
What's the most common cause of severe acute liver injury
(ALT or AST > 10xULN)?
Chances are, in your hospital, a sky-high ALT earns six pints worth of serologic tests
A few months ago, I saw someone check Parvo
Parvo is the new EBV
A few months ago, I saw someone check Parvo
Parvo is the new EBV
But ... what ACTUALLY causes severe acute liver injury?
Check out this multicenter study (community/transplant/VA) led by THE @tony_breu - hot off the presses
Top 3:
- Ischemic hepatitis
- Stones / biliary causes
- Drugs
ref: cghjournal.org/article/S1542-…
Check out this multicenter study (community/transplant/VA) led by THE @tony_breu - hot off the presses
Top 3:
- Ischemic hepatitis
- Stones / biliary causes
- Drugs
ref: cghjournal.org/article/S1542-…
Notice...blood tests may not find the top 3
There are 4 types of blood tests for ALI:
1: HAV/HBV/HCVtylenol
2: Things that never-ever cause ALI (Fig1)
3: Things that are occ. helpful and often misleading (Fig2)
4: Things the AGA recommends NOT testing (ceruloplasmin, Fig 3)
There are 4 types of blood tests for ALI:
1: HAV/HBV/HCVtylenol
2: Things that never-ever cause ALI (Fig1)
3: Things that are occ. helpful and often misleading (Fig2)
4: Things the AGA recommends NOT testing (ceruloplasmin, Fig 3)
Knowing the true DDx tells us what 2 do
1. Drugs: Start NAC if tylenol! If not, NAC still ok (Fig1)
2. Acute CBD stones happen! (Fig2). Ultrasound vs MRCP --> ERCP.
3. Ischemic hepatitis... see act 2
Summary (Fig 3): Stepwise testing for severe ALI
journalofhospitalmedicine.com/jhospmed/artic…
1. Drugs: Start NAC if tylenol! If not, NAC still ok (Fig1)
2. Acute CBD stones happen! (Fig2). Ultrasound vs MRCP --> ERCP.
3. Ischemic hepatitis... see act 2
Summary (Fig 3): Stepwise testing for severe ALI
journalofhospitalmedicine.com/jhospmed/artic…
Act 2:
Who gets ischemic hepatitis?
1. It's not just about hypotension!(Fig1) If it was, every patient in the ICU would have ALI.
2. 90-100% of patients w/ischemic hepatitis have CHF, almost always right heart failure (Fig1-2)
3. Indeed, 🔼ALT is a risk biomarker in CHF (Fig3)
Who gets ischemic hepatitis?
1. It's not just about hypotension!(Fig1) If it was, every patient in the ICU would have ALI.
2. 90-100% of patients w/ischemic hepatitis have CHF, almost always right heart failure (Fig1-2)
3. Indeed, 🔼ALT is a risk biomarker in CHF (Fig3)
The mechanism of ischemic hepatitis:
1. Liver has dual blood supply. 75% portal vein(5mmHg), 25% hepatic artery(Fig1)
2. CHF▶️congestion▶️venous htn >portal pressure🔽o2 diffusion in sinusoid
3. Liver arterializes▶️dependent on hep art(Fig2)
4. Transient🔽BP▶️🔥(Fig3)
1. Liver has dual blood supply. 75% portal vein(5mmHg), 25% hepatic artery(Fig1)
2. CHF▶️congestion▶️venous htn >portal pressure🔽o2 diffusion in sinusoid
3. Liver arterializes▶️dependent on hep art(Fig2)
4. Transient🔽BP▶️🔥(Fig3)
Why tweet about this?
1. Ischemic hepatitis is common and deadly.(Fig1) Often unrecognized.
2. I suspect right CHF is under-recognized. Correct me if wrong
3. While you are checking liver labs, please think about ischemic hepatitis and right HF.
ref: sciencedirect.com/science/articl…
1. Ischemic hepatitis is common and deadly.(Fig1) Often unrecognized.
2. I suspect right CHF is under-recognized. Correct me if wrong
3. While you are checking liver labs, please think about ischemic hepatitis and right HF.
ref: sciencedirect.com/science/articl…
This concludes a #livertwitter #tweetorial on ischemic hepatitis. I hope you enjoyed it. Thanks as always to @tony_breu for his #meded-inspiration
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