Today's morning report featured an interesting case of Alcoholic hepatitis.
There were multiple learning points including:
a)
Alcoholic hepatitis is a frequently
under-diagnosed condition which has a high morbidity and mortality. It is
characterized by elevations in liver enzymes (typically with AST:ALT ratio
greater than 2:1, though rarely over 300, fever, altered mentation, elevated
bilirubin and elevated INR. The diagnosis is made clinically based
on the previous historical and laboratory elements and a clinical history
consistent with alcohol abuse. The alcohol ingestion may precede the
development of hepatitis by weeks in some cases. Maddrey’s discriminant
function, based predominantly on the Prothrombin Time (not the INR) and the
bilirubin level is useful in distinguishing whether or not the patient would
benefit from corticosteroid therapy.
b)
Abdominal pain in a patient with known cancer has
a wide differential including bony metastases/hypercalcemia.
c)
Gastrointestinal bleeding in a patient with
suspected liver disease could be the result of variceal hemorrhage.
Further Reading:
Lucey, M. R., Mathurin, P., & Morgan, T. R. (2009). Alcoholic hepatitis. New England Journal of Medicine, 360(26), 2758-2769.
Thursz, M. R., Richardson, P., Allison, M., Austin, A., Bowers, M., Day, C. P., ... & Forrest, E. H. (2015). Prednisolone or Pentoxifylline for Alcoholic Hepatitis. New England Journal of Medicine, 372(17), 1619-1628.
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