• Palmar erythema -> palms not just red and mottled but also pillowy and tufty
  
  

  Posted 09/19/16 10:02:03 AM by Anna Krigel

• Acute Liver Injury
  • Elevated transaminases (if higher than 1000s think drug-induced, acute viral hepatitis, ischemic injury, possibly autoimmune hepatitis)
  • Hyperbilirubinemia
  • AKI
  • Mild hypoglycemia
  • Coagulopathy (INR>1.5)
  
  Acute Liver Failure
  • All elements of acute liver injury
  • Altered mental status, asterixis, encephalopathy
  
  

  Posted 09/19/16 10:10:23 AM by Anna Krigel

• Clues in the hepatic function panel
  • Globulin gap in a young woman with acute liver injury or failure points to autoimmune hepatitis
  • Low alkaline phosphatase in a patient with acute liver injury or failure points to Wilson's disease (can present at almost any age)
  
  

  Posted 09/19/16 10:11:52 AM by Anna Krigel

• Acute liver injury work up
  • acetaminophen level, Utox
  • Viral serologies (HAV, HBV, HCV, HSV)
  • ANA, Anti-smooth muscle Ab, Anti-mitochondrial Ab, Anti-LKM-1, immunoglobulin levels
  • Iron studies
  • Ceruloplasmin, 24 hour urine copper (because ceruloplasmin is an acute phase reactant and will be high in acute settings)
  • HIV
  
  

  Posted 09/19/16 10:16:10 AM by Anna Krigel

• Autoimmune hepatitis
  • Type 1 (80%) -> more classic presentation, seen in young women, see positive ANA, anti-smooth muscle Ab, elevated IgG levels, and plasma cell infiltrate on histology
  • Type 2 (20%) -> seen in pediatric patients, have positive anti-LKM-1 Ab
  • Induction therapy is with high dose glucocorticoids with or without azathioprine
  • Up to 80% of patients achieve remission after induction therapy, then glucocorticoids can be tapered, though 50-90% of patients will relapse within 12 months of drug tapering
  • Can be maintained on low dose prednisone or azathioprine
  
  

  Posted 09/19/16 10:18:49 AM by Anna Krigel

• For further reading...

  IV NAC in Early Stage Non-acetaminophen Acute Liver Failure (Gastroenterology 2009)
  Autoimmune Hepatitis (NEJM)
  
  

  Posted 09/19/16 10:24:20 AM by Anna Krigel

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