Moffitt Pearls 6.14.17 – GI Report

Pearls 6.14.17 – GI – Morning Report

Thank you to Salman for presenting an amazing case of a young woman with history of EtoH hepatitis p/w with fatigue, lightheadedness found to be severely anemic with evidence of active hemolysis and new cirrhosis. Work-up is ongoing.

**KEY PEARLS**

  1. Acute alcoholic hepatitis is a chronic disease (despite the name!). Presentation is based on predominantly cumulative burden – a single binge in a patient with otherwise minimal alcohol intake is unlikely to cause severe alcoholic hepatitis.
  2. In a young patient (< 35 yo) with new diagnosis of liver injury consider genetic causes including Wilson’s, hemochromatosis and alpha-1 antitrypsin disease in addition to autoimmune, vascular and infectious hepatitis.
  3. The smear and reticulocyte count are the key initial lab studies to frame your differential for hemolytic anemia.

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For those who want more information:

Alcoholic Hepatitis

The clinical syndrome of acute alcoholic hepatitis includes the following compilation of laboratory and clinical features:

  • Moderately elevated transaminases in a 2:1 ratio of AST/ALT
    • Typically less than 300, rarely greater than 500
  • Elevated bilirubin and Jaundice
    • Jaundice generally develops within 3 months prior to presentation
  • Fever & Neutrophilic Leukocytosis
    • Both should only be ascribed to alcoholic hepatitis after ruling out infection!
  • Right upper quadrant pain – can often palpate tender hepatomegaly
  • Clinical history of chronic drinking with or without recent bing
    • It’s not uncommon that patients have actually decreased their drinking in the weeks-months preceding acute alc hep due to the onset of symptoms with alcohol intake.

See this RCT from NEJM regarding pentoxifylline vs. prednisolone for the treatment of alcoholic hepatitis. Bottom line:  Acute alcoholic hepatitis is a profoundly morbid disease with very high mortality (30-40% in 6 months).  Prednisolone was associated with a reduction in 28-day mortality, but did not reach significance and there were no improvements in 90-day or 1 year mortality.

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Approach to abnormal liver function tests (table from UptoDate.com):

table

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Approach to Hemolytic Anemia:

Picture2.png

 

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