VA Morning Report 6.6.17: Ascites, transaminitis and decompensated cirrhosis

CASE SUMMARY
Scott Bauer presented a great case of a 51M with EtOH use disorder who presented with subacute abdominal pain, distention and jaundice initially concerning for alcoholic hepatitis, ultimately found to have decompensated alcoholic cirrhosis.

TOP PEARLS
1. Distinguishing ascites from other causes of abdominal distention is challenging. Consider supplementing your physical exam with bedside ultrasound.
2. The ratios of liver enzymes can provide strong clues about the etiology of liver injury – AST/ALT > 2 is highly suggestive of alcohol-related liver disease.
3.  Patients with cirrhosis are at risk of decompensation from a wide variety of factors including:
  • Vascular injury (portal vein thrombosis)
  • Infection (viral hepatitis, SBP, PNA, UTI)
  • Malignancy (HCC)
  • GI bleeding
  • Toxins/Meds (alcohol, acetaminophen, NSAIDs, diuretics)

ASCITES
The cause of abdominal distention can categorized into
  1. Solid
    • Hepatomegaly
    • Splenomegaly
    • Adiposity
    • Malignancy
  2. Liquid
    • Ascites
  3. Gas
    • Bowel obstruction/ileus

Several physical exam maneuvers can help distinguish these causes (e.g careful palpation for organomegaly, assessment for tympany, and fluid wave).

A bedside ultrasound is a great addition to this tool box.


LIVER ENZYMES
Here is one approach (anatomic) to the DDx of transaminitis
The ratio of liver enzymes can also inform the DDx.
AST/ALT > 2
  • Extra-hepatic AST
    • Rhabdo
    • Hemolysis
    • Massive MI
  • Toxin-induced disease
    • Alcohol
    • Amiodarone
    • Vitamin A
Alk Phos/Tbili <4
  • Wilsons
ALT/LDH 
  • ALT/LDH < 1.5 suggests ischemic hepatopathy
  • ALT/LDH > 1.5 suggests tylenol or viral hepatitis.

DECOMPENSATED CIRRHOSIS
Decompensation refers to (1) worsening synthetic function (hepatic encephalopathy, hypoglycemia, coagulopathy) or (2) increased portal hypertension (increased ascites, variceal bleeding, hepatorenal syndrome) in a patient with cirrhosis.
While progression of the underlying disease is a common cause of decompensation, carefully assess for these possibilities:
  • Vascular injury (portal vein thrombosis)
  • Infection (viral hepatitis, SBP, pneumonia, UTI)
  • Malignancy (HCC)
  • GI bleeding
  • Toxins/Meds (alcohol, acetaminophen, NSAIDs, diuretics)
Evernote: https://www.evernote.com/l/AGICS9Hun4VNhqxv4fz4Cpy9UIJhtFzni48
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