Day #16 - Hepatitis

Today we talked about a patient with acute hepatitis with transaminases ~1000 in a hepatocellular pattern.

There are a limited number of causes of such an acute hepatitis:

• Viral hepatitis (Hep A, Hep B, Hep C, HSV/CMV)
• Toxic Hepatitis --> tylenol, toxic mushrooms, severe ETOH (AST/ALT rarely above the 100's), other
• Stone in the common bile duct
• Ischemic Hepatitis/Shock Liver/Acute R-sided CHF
  
• Budd-Chiari Syndrome
• Autoimmune, Wilson's, Pregnancy, Aggressively infiltrating cancer
  

From Wallach, Interpretation of diagnositic tests (2006):
"Rapid rise of AST and ALT to [>600] followed by sharp fall in 12-72h is said to be typical of acute bile duct obstruction due to a stone"

... The caveat is that if you have a fulminant hepatitis the AST/ALT may decrease because there are no hepatocytes left to die. So it is all in the clinical context.

The discussant was suspicious that this was a case of a biliary stone despite the stone not being seen on ultrasound. This raises an important point. We often rely on imaging to help make the diagnosis; however, we need to be mindful that even the best imaging tests can be falsely negative. I am reminded of the axiom "a rare presentation of a common disease is most likely than a common presentation of a rare disease"

The team also very astutely decided to treat for potential paracetamol/acetaminophen toxicity based on the patient's medication history. There is a great article in NEJM which talks about the treatment of acetaminophen poisoning.