HEPATOLOGY

Take a focused history from a stable patient presenting with acute liver injuty, to include past medical history, drug and allergy history, social history and family history. Consider asking in more detail about relevant risk factors for liver disease including alcohol, drugs (e.g. paracetamol, other herbal or over-the-counter medications or other toxins), tattoos, travel and sexual history.

If appropriate, examine the patient and report on any clinical signs of chronic liver disease.

For the patient you have seen, consider:

• What differential diagnoses have you considered for the patient you have seen? Give two features from the history/examination that support each one.
• What investigations would you do to assess the severity of the patient's condition?
• What investigations would you do to determine the underlying cause?

Consider:

1. What bloods tests make up 'liver function tests'?
2. Which tests assess synthetic function of the liver?
3. What is the difference between intra-hepatic and cholestatic pictures of blood chemistry? Give an example of LFTs in the conditions above and three causes of each.

Review the blood tests including liver screen for the patient you have seen. What do you think was the most likely cause of the patient's liver injury?

Paracetamol overdose (intentional and unintentional) is a common cause of acute liver injury.

Consider:

1. What extra tests should be ordered in suspected paracetamol overdose?
2. What is the treatment of paracetamol overdose?
3. What are the criteria for ITU involvement and liver transplant? (Look up the King’s College Criteria)

Find a drug chart and practice prescribing the NAC infusion for the first 21 hours. Click here for the Royal College of Emergency Medicine guidelines for prescription of N-acetylcysteine.

• What is the role of liver ultrasound in the assessment of acute liver injury? What conditions may be detected on ultrasound?
• What supportive therapy is important in the management of patients with acute liver injury?

Highlight three key things you have learned today. Summarise them on a post-it note and keep it somewhere you will find in a week or two.

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1. https://www.uptodate.com/contents/acute-liver-failure-in-adults-etiology-clinical-manifestations-and-diagnosis#H414607198
2. https://radiopaedia.org/articles/budd-chiari-syndrome-1
3. https://radiopaedia.org/articles/acute-hepatitis?lang=us
4. https://livertox.nih.gov/Phenotypes_fail.html
5. https://newbp.bmj.com/topics/en-gb/1010
6. https://www.rcem.ac.uk/docs/Clinical%20Standards%20and%20Guidance/LRI%20ED%20paracet%20docu-90%20for%20RCEM.pdf
7. https://www.toxbase.org/