Acute Hepatitis Management/Disposition

[waterski232002]

I had a 45 yo F w/ a history of chronic etoh abuse who came in intoxicated today and c/o 2-3 weeks of generalized abdominal pain, N/V/D. No Fevers or chills. On exam she had moderate diffuse TTP, most prominent in her RUQ.

Her labs revealed a normal CBC, BMP, Lipase, but elevated LFTs (AST 1400, ALT 1300, AP normal, Tbili normal). Her last set of LFTs from 4 months ago were totally normal. She denied heavy tylenol use, was able to tolerate orals.... My plan was to discharge her home pending normal coags & a neg CT abdo/pelvis. I sent an acute viral hepatitis panel for her primary to follow up on.

I'm curious how most of you guys manage patients you diagnose with acute undifferentiated hepatitis in the ER. Do you routinely image these patients in the ER (US or CT)? Do you discharge them with an acute hepatitis panel pending and have them follow-up with their primary doctor? Do you only admit patients who are toxic, have refractory emesis, or abnormal coags?

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[12R34Y]

I had a 45 yo F w/ a history of chronic etoh abuse who came in intoxicated today and c/o 2-3 weeks of generalized abdominal pain, N/V/D. No Fevers or chills. On exam she had moderate diffuse TTP, most prominent in her RUQ.

Her labs revealed a normal CBC, BMP, Lipase, but elevated LFTs (AST 1400, ALT 1300, AP normal, Tbili normal). Her last set of LFTs from 4 months ago were totally normal. She denied heavy tylenol use, was able to tolerate orals.... My plan was to discharge her home pending normal coags & a neg CT abdo/pelvis. I sent an acute viral hepatitis panel for her primary to follow up on.

I'm curious how most of you guys manage patients you diagnose with acute undifferentiated hepatitis in the ER. Do you routinely image these patients in the ER (US or CT)? Do you discharge them with an acute hepatitis panel pending and have them follow-up with their primary doctor? Do you only admit patients who are toxic, have refractory emesis, or abnormal coags?

I had this case yesterday. Guy came in who regularly drinks (2-3 times per week, yeah right) with ruq/epigastric pain. Was kind of writhing around in bed and was having these "attacks" that would last about 10 minutes. vitals, ekg normal during attacks.

Anyway....no n/v/d, just ruq/epigastric pain. gave him a GI cocktail, zantac, got some labs, CXR, I looked at his aorta/fast (more for fun and he was skinny so great pictures).

Sent some belly labs and LFT's, AST/ALT were like 500's. T.bili normal. He already had Gallbladder out as well.

Anyway..........PO challenged and sent home with follow up for "hepatitis" of unknown origin. probably drinking in this guy, but who knows.

so, our plan was if he failed PO challenge or if his "attack" returned after the GI cocktail/zantac while he was obs in the ER we would get a CT abd/pelvis, but he did fine and left.

later

 

[WilcoWorld]

I've seen it twice, and I basically do exactly what Waterski did +/- the CT scan (depending on exam findings). The way I see it cogs are the key. The way my attending put it, "PT is the most important LFT".

Interstingly enough, I once saw a hepatitis bounce-back who was d/c'd on Reglan for nausea control and came back complaining of "breast discharge".

Anyone care to offer a diagnosis?

 

[Hayduke]

Interstingly enough, I once saw a hepatitis bounce-back who was d/c'd on Reglan for nausea control and came back complaining of "breast discharge".

Anyone care to offer a diagnosis?

cirrhotic gynecomastia

 

[Rendar5]

cirrhotic gynecomastia

May have had that but Reglan prolly was what caused the discharge from the developed breast tissue. Dopamine blockers tend to do that. (by increasing prolactin levels).

 

[MasterintuBater]

pregnancy

 

[WilcoWorld]

May have had that but Reglan prolly was what caused the discharge from the developed breast tissue. Dopamine blockers tend to do that. (by increasing prolactin levels).

That was my theory: Antidopaminergic med --> disinhibited prolactin release --> pseudo-lactation.

Switched her to ondansetron & the "discharge" stopped.