Rosen & Barkin's 5-Minute Emergency Medicine Consult (336 page)
Read Rosen & Barkin's 5-Minute Emergency Medicine Consult Online
Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen
Tags: #Medical, #Emergency Medicine
BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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See Also (Topic, Algorithm, Electronic Media Element)- Abdominal Trauma, Blunt
- Abdominal Trauma, Penetrating
- Abdominal Trauma, Imaging
- Colon Trauma
- Diaphragmatic Trauma
- Pancreatic Trauma
- Renal Injury
- Small Bowel Injury
- Trauma, Multiple
CODESICD9
- 864.00 Injury to liver without mention of open wound into cavity, unspecified injury
- 864.10 Injury to liver with open wound into cavity, unspecified injury
- 864.11 Injury to liver with open wound into cavity, hematoma and contusion
ICD10
HEPATITIS- S36.112A Contusion of liver, initial encounter
- S36.118A Other injury of liver, initial encounter
- S36.119A Unspecified injury of liver, initial encounter
Jason Koob
•
Christopher T. Richards
BASICSDESCRIPTION
- Inflammation of the liver owing to infectious, toxic, and autoimmune disorders
- Progression from hepatocellular injury (hepatitis) to scarring (cirrhosis)
- Progression from hepatocellular injury (hepatitis) to scarring (cirrhosis)
- Infectious causes are the most common
- Unknown etiology in 5–10% of acute and chronic hepatitis cases and up to 50% in fulminant hepatic failure (FHF)
- Hepatitis A (HAV):
- Transmission: Fecal–oral
- Incubation period: 2–7 wk
- FHF in 0.1%
- No chronic phase
- 10% will have a relapsing course over months
- 10% will have a relapsing course over months
- Transmission: Fecal–oral
- Hepatitis B (HBV):
- Transmission: Mucous membrane, percutaneous exposure to bodily fluids, perinatal
- Incubation period: 8–22 wk
- Subclinical in 70%
- FHF in 1%
- Risk of chronic hepatitis increased with age at infection and comorbidities:
- Neonatal: >90%
- Infant: 50%
- Child: 20%
- Immunocompetent adult: 1–5%
- Immunocompromised adult: 50%
- Neonatal: >90%
- Risk of cirrhosis, hepatocellular carcinoma
- Transmission: Mucous membrane, percutaneous exposure to bodily fluids, perinatal
- Hepatitis C (HCV):
- Transmission: Blood >> sexual and perinatal
- Incubation period: 6–10 wk
- FHF rare
- 80% progress to chronic disease
- Risk of cirrhosis, hepatocellular carcinoma
- Transmission: Blood >> sexual and perinatal
- Hepatitis D (HDV):
- HDV can be transmitted only in the presence of HBV infection
- 2 patterns of infection: Simultaneous infection with HBV and HDV or HDV superinfection in an individual with chronic HBV
- 2 patterns of infection: Simultaneous infection with HBV and HDV or HDV superinfection in an individual with chronic HBV
- Same transmission as HBV
- Incubation period: 3–7 wk
- FHF in 3%
- 5% progress to chronic disease
- Risk of cirrhosis 3 times higher in HDV-infected individual compared with HBV infection alone
- HDV can be transmitted only in the presence of HBV infection
- Hepatitis E (HEV):
- Most common cause of acute hepatitis and jaundice worldwide
- Rarely found outside developing countries
- Typically seen as outbreaks
- Transmission: Fecal–oral, waterborne, foodborne
- Incubation period: 3–8 wk
- FHF in 10%
- Chronic infection almost exclusively in immunocompromised persons
- Most common cause of acute hepatitis and jaundice worldwide
- Alcoholic hepatitis:
- Associated with >14 drinks/wk in women and >21 drinks/wk in men
- Sequelae of chronic use:
- Hepatic steatosis in 90–100%
- Hepatitis in 10–35%
- Cirrhosis in 5–15%
- Hepatic steatosis in 90–100%
- Increased association with chronic viral hepatitis
- Maddrey discriminant function (MDF) ≥32 associated with only 50–65% survival
- MDF = 4.6 × [prolongation of PT above control](s) + serum bilirubin(mg/dL)
- MDF = 4.6 × [prolongation of PT above control](s) + serum bilirubin(mg/dL)
- Associated with >14 drinks/wk in women and >21 drinks/wk in men
- Abscess-induced hepatitis:
- Entamoeba histolytica, pyogenic
- Entamoeba histolytica, pyogenic
- Secondary hepatitis viruses:
- CMV, EBV, HSV, HIV
- CMV, EBV, HSV, HIV
- Medication and toxin induced
- Autoimmune hepatitis:
- Display concurrent stigmata of autoimmune disease
- Display concurrent stigmata of autoimmune disease
- Vast majority of cases are caused by HAV
- Perinatal HBV infection develops into chronic disease 90% of the time
- 20% case fatality for HEV during pregnancy.
- Acute fatty liver of pregnancy (AFLP):
- May progress to DIC
- May progress to DIC
- H
emolysis,
E
levated
L
iver enzymes, and
L
ow
P
latelets (HELLP) syndrome - Immunoprophylaxis is safe during pregnancy
DIAGNOSISSIGNS AND SYMPTOMS
- Often asymptomatic
- Preicteric phase:
- Often misdiagnosed as a nonspecific viral syndrome or gastroenteritis
- Often misdiagnosed as a nonspecific viral syndrome or gastroenteritis
- Icteric phase:
- Present in 70% of HAV, 30% of HBV, and 20% of HCV
- Present in 70% of HAV, 30% of HBV, and 20% of HCV
- FHF:
- Coagulopathy
- Encephalopathy
- Cerebral edema
- Coagulopathy
- Preicteric phase:
- Fever, chills
- Malaise
- Nausea, vomiting, anorexia
- Arthralgia
- Aversion to smoking
- Fever, chills
- Icteric phase:
- Jaundice
- Dark urine
- Light stools
- Pruritus
- Rash
- Right upper quadrant pain
- Jaundice
- FHF:
- Bleeding
- Altered mental status
- Bleeding
- Preicteric phase:
- Fever
- Arthritis
- Dehydration
- Fever
- Icteric phase:
- Fever
- Icterus of skin, sclerae, mucous membranes, and tympanic membranes
- Nonspecific maculopapular or urticarial rash
- Dehydration
- Tender hepatomegaly
- Fever
- FHF:
- Bruising
- Disorientation
- Asterixis
- Bruising
- Detailed history of risk factors for hepatitis, including toxic exposure and drug use
- Viral serologies are the mainstay of diagnosis of viral causes
Lab
- CBC with differential
- Basic metabolic panel:
- Azotemia with hepatorenal syndrome in FHF
- Hypoglycemia with severe liver damage
- Hyponatremia
- Azotemia with hepatorenal syndrome in FHF
- LFTs:
- Elevation in transaminases reflects hepatocellular injury
- Degree of elevation does not always correlate with severity
- If alkaline phosphatase more than 4 times normal, consider primary cholestatic process rather than viral hepatitis.
- Mild to moderate elevation of conjugated bilirubin due to decreased excretion
- Elevation in transaminases reflects hepatocellular injury
- Amylase, lipase may indicate pancreatic or biliary etiology
- PT/PTT/INR, albumin
- Measure of synthetic function of liver
- Prolonged INR reflects more severe injury
- Measure of synthetic function of liver
- Ammonia level:
- For patients with altered mental status
- For patients with altered mental status
- Viral serologies:
- HAV:
- Anti-HAV IgM: Acute infection
- Anti-HAV IgG: Previous exposure, immunity
- Anti-HAV IgM: Acute infection
- HBV:
- HBsAg: Acute infection (appears before symptoms), chronic infection
- Anti-HBs: Past infection, carrier state, postimmunization
- Anti-HBc IgM: Acute infection
- Anti-HBc IgG: Past infection, chronic infection, carrier state
- HBeAg: Acute infection, some chronic states
- Anti-HBe: Past infection, chronic infection, carrier state
- Postimmunization: Anti-HBs only
- HBsAg: Acute infection (appears before symptoms), chronic infection
- HCV:
- Anti-HCV: Acute infection, chronic infections, first-line test
- HCV RNA: Acute infection, chronic infections; confirmatory
- Anti-HCV: Acute infection, chronic infections, first-line test
- HDV: Anti-HDV or viral RNA, not routine
- HEV:
- Anti-HEV IgM: Acute infection, detectable for only 3–12 mo
- Anti-HEV IgG: Persists for years, if not for life
- Anti-HEV IgM: Acute infection, detectable for only 3–12 mo
- HAV:
- α-fetoprotein:
- For chronic HBV or HCV to evaluate for hepatocellular carcinoma
- For chronic HBV or HCV to evaluate for hepatocellular carcinoma
- Monospot: For EBV
- Urinalysis for bilirubin
- Head CT to evaluate hepatic encephalopathy
- RUQ US to evaluate for biliary obstruction
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