Thread by @AnnKumfer

1/The other day, I was looking at the chart of a patient who was admitted overnight for afib with RVR. Labs:
AST 11,000, ALT 8000, Tbili 7 (direct bili 5), Alk phos 230, INR 4.35 (not on AC)
Woah! I wanted to take some time to run through a differential.

2/ I find it is helpful to run through this check list
1. New or old? Hepatic panel 4 months ago was normal aside from mild alk phos 🔼
2. Hepatocellular vs Cholestatic process- This is hepatocellular pattern predominately although Tbili is elevated
3. Degree of elevation

3/When I think of ALT/AST in the 1000s I think of 5 main categories: Clot/obstruction, toxin (acetaminophen, herbal, mushroom ect), acute viral hepatitis, ischemic hepatitis, and autoimmune. Check at this great @CPSolvers @jackpenner schema.

4/However, when liver enzymes > 75x 🔼, 90% pf time ddx either due to toxin or ischemic hepatitis.

Both toxin and ischemia have 🔼AST/ALT ratio initially (has to due to due with expression of AST in mitochondria) However, AST has a quick ½ life, so will fall quickly.

5/Here it is helpful to review medication list and ask about ingestion/supplements. It is also helpful to review BP. However, in one retrospective analysis, hypotension was only present 38% of the time prior to liver dysfunction (studies ranged from 14-100%). PMID: 26299319

6/ Which laboratory test is helpful in evaluating for ischemic hepatitis?

7/ The patient’s LDH was 12,000. Studies show that an ALT/LDH ratio < 1 is associated with ischemic hepatitis.

Which comorbidity is most associated with the development of ischemic hepatitis?

8/Studies show that heart failure is associated with development of ischemic hepatitis.
In one study ( PMID 9600366 ),incidence of L HF (88.2%), right HF (67.6%), COPD (58.8%), and chronic renal failure (55.9%).
Another study (PMID: 10967151) 94% had R-sided HR

9/ The value that was less c/w ischemic hepatitis was the bilirubin of 7. Most studies show average bilirubin around 2-4 (see above chart). Liver ultrasound with doppler without obstruction seen. Bilirubin may lag behind liver enzymes.

10/ Ischemic hepatitis is associated with a high mortality rate up to 51% in hospital mortality (PMID: 26299319) which is due to the underlying conditions which also caused the development of ischemic hepatitis rather than a result of hepatic dysfunction.

11/ Here is a great review of liver enzyme alterations I read as I was thinking through this case.

ncbi.nlm.nih.gov/pubmed/15684121