Transcript A young man with vomiting

HKCEM College Tutorial
A woman
with
Vomiting
Author
Dr. E Yuen
Revised by
Dr. Wong Cheung Lun, William
May 2013
Triage Notes
▪ Re-attend case
▪ 43 years-old female
▪ Repeated vomiting
▪ BP 80/40 P140, RR 26
Triage Category II
History
▪ Vomiting for 1-2 days
▪ Vague epigastric discomfort
▪ Normal bowel opening
▪ Unable to tolerate fluid for past 1-2 days
▪ Attended AED yesterday & diagnosed as “GE”,
▪ Discharged home with Holopon
Any further questions?
History
▪ Vomitus: yellowish fluid, no coffee ground
▪ Vague epigastric pain with vomiting
▪ Pain free in between
▪ No recent travel and no clustering of cases
▪ History of appendicectomy 1 year ago
▪ No known drug allergy
▪ Clerical work, no smoking or drinking
▪ LMP 1 month ago
Examination
▪ Fever 37.9oC, Dehydrated, Lethargic
▪ CVS: Tachycardia, Hypotensive
▪ Resp: AE equal, no added sound
▪ Abdomen
▪ Soft, Non tender, Bowel sound normal
▪ No organomegaly
▪ Grid-iron scar
What is your Immediate Management?
Immediate stabilization
▪ Shock! Resuscitation STAT!
▪ A, B - oxygen
▪ C - Immediate fluid replacement
▪ Treat underlying problem
What type of shock is likely in this patient?
Causes of Shock
▪ Hypovolemic
▪ Fluid loss
▪ Hemorrhagic
▪ Distributive
▪ Sepsis/SIRS
▪ Anaphylaxis
▪ Cardiogenic
▪ Myocarditis
▪ Myocardial infarction
▪ Obstructive
▪ Pulmonary Embolism
▪ Aortic Dissection
▪ Cardiac Tampanode
What type of shock is likely in this patient?
What TESTS would you like to do?
Tests
▪ H’stix
▪ DKA
▪ Blood gases
▪ Acidosis –
shock/sepsis/poisoning
▪ RLFT, Amylase
▪ Renal failure
▪ Hepatitis
▪ Pancreatitis
▪ Ultrasound
▪ Assessment of shock
▪ Urine
▪ Ketone
▪ Dehydration, DKA
▪ WBC, Nitrite
▪ Urosepsis
▪ Urobilinogen, Bilirubin
▪ Hepatitis, Biliary obstruction, Hemolytic disease
▪ Pregnancy Test
▪ Ectopic Pregnancy
▪ CBC
▪ WBC - Infection
▪ Hb - Hemorrhage blood lost
▪ Plt – Infection, DIC
Imaging
▪ CXR
▪ Free gas under diaphragm
▪ Pneumonia
▪ Cardiomegaly (Myocarditis)
▪ AXR
▪ Intestinal obstruction
▪ Gastric dilatation
▪ Gastroparesis in DM
▪ USG
▪ ECHO
▪ LV Contractility
▪ RV dilatation
▪
▪
▪
▪
▪
▪
IVC collapse index
Intra-abdominal free fluid
Biliary sepsis/Liver abscess
HCC/AAA
Hydronephrosis
Ectopic pregnancy
▪ Abnormal shadow
▪ Abscess
▪ Aerobilia
▪ Appendicolith
▪ CT brain
▪ Suspected increase ICP
if headache/decreased GC and
repeated vomiting
The story continue...
▪ After fluid replacement  BP 100/50, HR 100
▪ Notice tingle of jaundice at sclera
▪ Urine multistix
▪ Urobilinogen 4+, Bilirubin 2+, Ketone 2+
▪ H’stix 3.6
How to interpret the findings?
What cause elevated Urobilinogen
and Bilirubin?
↑ Urinary Urobilinogen
↑ Urinary Bilirubin
▪ Liver Disease
▪ Hemolytic disorder
▪
▪
▪
▪
Testing Reagents
p-dimethylaminobenzaldehyde
Hepatitis
Cirrhosis
Other liver disorders
Biliary obstruction
Testing Reagents
2,4-dichloroaniline diazonium salt
Urine Urobilinogen
Urine Bilirubin
Normal
+++
Liver damage
++
+ or -
Hemolytic disease
+++
Negative
Bile duct obstruction
What next?
Bilirubin
ALT
AST
ALP
GGT
INR
WBC
360 μmol/l
6150 IU/L
5650 IU/L
190 IU/L
20 IU/L
3.8
15 x 109/L
Diagnosis
▪ Acute Liver Failure likely diagnosis
- Clinical manifestation of sudden and severe hepatic injury
▪ Fulminant Hepatic Failure
▪ First used in 1970
▪ Potentially reversible disorder that was result of severe liver injury with onset
of encephalopathy within 8 weeks of symptom in the absence of pre-existing
liver disease
▪ In young children, encephalopathy could be absent or late
What is the likely cause at this point?
Clinical Features
▪ General
▪ SIRS
▪ Hyper-metabolic status
▪ Liver
▪
▪
▪
▪
↓Gluconeogensis – HypoG
↓Lactate clearance – Lactic acidosis
↓NH3 clearance – ↑NH3
Coagulopathy
▪ Adrenal gland
▪ ↓Glucocorticoid - Hypotension
▪ Brain
▪ Encephalopathy
▪ Cerebral edema
▪ ↑ICP
▪ Kidney
▪ Lung
▪ ALI, ARDS
▪ Frequently AKI
Acute Liver Failure
Hyper-acute
Acute
Subacute
0-1 week
1-4 weeks
4-12 weeks
+++
++
+
Severity of jaundice
+
++
+++
Degree of intracranial hypertension
++
++
+/-
Good
Moderate
Poor
Paracetamol
Hepatitis A
Hepatitis E
Hepatitis B
Nonparacetamol
drug induced
liver injury
Time from jaundice to
Encephalopathy
Severity of coagulopathy
Survival rate without emergency
liver transplant
Typical cause
▪ Causes – wide geographical variation
▪ Developing world – Hepatitis A, B, E accounting for most cases
▪ Developed world – Drug induced liver injury
▪ In Hong Kong / SE Asia
▪ High prevalence of Hepatitis B infection
Acute Liver Failure – Viral Hepatitis
HAV
HBV
HCV
HDV
HEV
0.01%-0.1%
1.0%
Very rare
Co: 1%-10%
Super: 5%-20%
Pregnant:
20%
Risk factors for
ALF
HBV, HCV
Age>40
IVDA
Alcohol
Females
HCV
HBV
Chronic HBV
Pregnancy
Clinical course
Hyperacute
Acute
Subacute
Acute
Hyperacute
Spontaneous
survival after
ALF
40-60%
15-39%
IgM-anti HAV
IgM-anti HBc
HBsAg
HBV DNA
Risk of ALF
Diagnostic test
31-45%
Anti-HCV
HCV RNA
IgM-anti HDV
IgM-anti HBc
IgM-anti HEV
Co: Co-infection; Super: Superimposed infection of chronic HBV
Viral Hepatitis
▪ Aminotransferase sensitive but not specific
▪ AST: Mitochondria 80%, Cytosol 20%
▪ Liver, Heart, Skeletal muscle, Kidney, Brain, Pancreas, Lungs, RBC
▪ ALT: Only in Cytosol
▪ Outcome may not be correlated to degree of elevation
▪ Elevation greater than 10 times
▪ Associated extensive hepatocellular damage
▪ esp. in severe viral hepatitis, drug/toxin induced, ischemic
▪ AST:ALT<1: Viral hepatitis
▪ AST:ALT>1: Chronic liver injury
▪ Lack of elevation in ALT  ? Pyridoxine deficiency
▪ AST:ALT>2: Alcoholic liver disease (seldom > 500 IU/L)
The story continue...
▪ Patient did not have history of hepatitis
▪ Previous body check revealed
▪ HBsAb +ve
▪ HBsAg –ve
▪ No recent travel
▪ Improper cooked seafood intake
What are the other causes of ALF?
Drug induced ALF
▪ Paracetamol overdose
▪ The most common cause
▪ Liver transaminase
▪ Rise within 12 to 24 hours post ingestion
▪ Peaking AST > ALT
▪ Significantly higher than for other cause
of ALF
▪ Usually observed 3 days post ingestion
▪ Peak bilirubin levels are lower than for
other causes
▪ Spontaneous survival rate is higher
Usually idiosyncratic reaction
Non-dose dependence
More sub-acute clinical course
The story continue...
▪ Patient did not have any depressed mood or
suicidal ideation
▪ Not on any chronic medications
What are the other causes of ALF?
Other causes of ALF
▪ Biological toxin
▪ Toxic Mushroom (Amanita phallodies, verna and virosa)
▪ Delay onset of vomiting
▪ Traditional herbal medication
▪ Diagnosis by exclusion
▪ Examples: 黃藥子(黃獨), 蒼耳子,望江南子(豬屎豆),雷公藤,蜈蚣粉,千里光,天
花粉,川楝子,川楝皮,苦楝皮,補骨脂(破故紙),何首烏
+ most of 31 scheduled 1 herbs
▪ Metabolic causes
▪ Acute Wilson disease
▪ Acute fatty liver of pregnancy, HELLP
▪ Autoimmune hepatitis
▪ Ischemic
▪ Shock liver, Budd-Chiari syndrome/Sinusoidal obstruction syndrome
The story continue...
▪ Patient has recent consumption of mushroom
▪ Found in country parks near the reservoirs
▪ Developed vomiting 6-8 hours after ingestion
Amanita Phallodies induced ALF
ALF Management
▪ Supportive care
▪ Multi-organ failure
▪ ICU for organ system support
▪ Underlying cause
▪ NAC
▪ Nucleotide analogue inhibitors
▪ MDAC, Penicillin, Silibinin
- Paracetamol overdose
- Hepatitis B
- Amanita poisoning
Liver Transplantation
▪ King’s college criteria
▪ Paracetamol
▪ pH<7.3 or HE 3 +, Cr 300 +
▪ INR 6.5
▪ Non-Paracetamol
▪ HE + INR 6.5+
▪ Or Any THREE
▪ INR 3.5 +
▪ Bil 300 +
▪ Age<10 or >40
▪ Unfavorable cause
▪ Clinically acceptable for specificity
▪ Survival without transplantation < 15%
▪ Sensitivity might be low
▪ However, so far no other criteria has shown
consistent and reproducibly better performance
Learning Point
▪ Vomiting + Diarrhea NOT ALWAYS GE
▪ Interpretation of Urine Urobilinogen/Bilirubin
▪ Interpretation of deranged LFT
▪ Look for precipitating cause of Acute Liver Failure
▪ Specific treatments may alternate outcome of patient
End
THANK YOU