A 45-year-old intellectually handicapped man is admitted to your Intensive Care Unit for airway management. He was nasally intubated for evacuation of a large dental abscess, which had caused airway compromise.
(c) Over the next 48 hours he develops increasing jaundice, with severe derangement of his Liver Function Tests. What are the likely causes, and how are you going to manage this problem?
(c) Over the next 48 hours he develops increasing jaundice, with severe derangement of his Liver Function Tests. What are the likely causes, and how are you going to manage this problem?
The potential causes of jaundice and abnormal LFTs within the first 72 hours are many. The pattern of elevation may help the diagnosis (eg. hepatocellular pattern [elevated transaminases, but minor elevation of Alkaline Phosphatase], cholestatic [minor elevation of transaminases]), and a systematic approach is helpful. Most likely causes include infection (systemic sepsis, mild hepatitic/intravascular cholestasis, liver abscess, acalculous cholecystitis), drug induced (cholestatic/hepatitic), haemodynamic/shock (ischaemic hepatitis) or haemolysis (sepsis, early destruction of transfused blood). Pre-existing intercurrent diseases (hepatitis, gall stones) could also be present.
Management depends on the specific/likely aetiology. A careful history (including drug history [eg. high dose of paracetamol before presentation]) and clinical examination (eg. signs of right heart failure, chronic liver disease, abdominal pain) followed by specific liver function tests to delineate the pattern of abnormality (including alkaline phosphatase [AP], gamma glutamyl transpeptidase [GGT] and/or conjugated/unconjugated bilirubin). More specific blood tests may be indicated (eg. haemolysis screen or viral serology). Imaging of right upper quadrant with ultrasound (to assess obstruction &/or stones) would usually be indicated (± other imaging eg. nuclear medicine or CT scan). After addressing the specific aetiology, further treatment would be largely supportive (with awareness of effects on drug metabolism).
The college has cheated the candidate by not presenting them with a list of LFTs to analyse. With no information, the differentials (and thus the manaement options) are distrubingly broad.
One can work though this systematically.
The following tests will need to be ordered, in order of escalating expense, invasiveness and esotericims:
Differentials and their management
In addition, one would need to adjust drug doses and dosing intervals to allow for changes in hepatic clearance.