HEPATITIS: EM Perspective - Dr. Yavorcik

It’s the history and physical that is going to guide you for clues to hepatitis.

• History: alcohol use, recent drug ingestions, IV drug use, blood transfusions.
• Physical Exam: RUQ pain, palpable liver, jaundice, icterus, ascites, encephalopathy
  

Orders matter... (at least where we work they do)

• "Costs": BMP - $180, POC CHEM 8 - $408, COMP - $230, LFTs - $200, Fractionated Bili $123.
• Order COMP instead of CHEM 8 if you plan on ordering a CBC anyway to be most cost effective if you can wait an extra 30 minutes for electrolytes.
  

Dr. Yavorcik -- at least according to G+

Liver Function Tests are more indicative of liver damage... not "function."

• AST/ALT released from parenchymal cells in liver into serum.

• PT/INR, aPTT, albumin, bilirubin show synthetic capabilities of the liver.

Be aware of different ranges of aminotransferases.

• Non-alcoholic fatty liver: AST and ALT up to 4x upper limit (150-200s)
• Alcoholic: AST up to 8x normal (400-500s), ALT up to 5x upper limit (200-250s)
• Chronic Hep B, C: may be normal, may be up to 10x limits (50-400s)
• Toxin-mediated or Acute Viral: AST and ALT up to 25x (can be around 1,000)
• Ischemic injury / shock liver: AST ALT up to 50x (1,000-2,000s)

• If AST/ALTs >10x normal limits think about obtaining acetaminophen level, serum pregnancy test, UA, toxicology screen, U/S of abdomen for vascular occlusion/Budd-Chiari Syndrome, ascites.

• ADMIT high-risk patients which includes pregnant and elderly who are not responding to supportive care. Look closely at total bilirubin if over 20 mg/dL, PT 50% above normal.

• ADMIT: Ascites with respiratory distress, abdominal pain as well as fever, acidosis, leukocytosis. Also admit new or worsening encephalopathy, coagulopathy with bleeding, severe hyponatremia, hyper/hypo-volemia.

• Aspects of hepatitis we can treat in the ED include ascites with paracentesis, albumin, SBP with cefotaxime, albumin, encephalopathy with lactulose, coagulopathy - vitamin K, FFP, donor platelets.