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Download A young man with vomiting
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HKCEM College Tutorial A woman with Vomiting Author Dr. E Yuen Revised by Dr. Wong Cheung Lun, William May 2013 Triage Notes ▪ Re-attend case ▪ 43 years-old female ▪ Repeated vomiting ▪ BP 80/40 P140, RR 26 Triage Category II History ▪ Vomiting for 1-2 days ▪ Vague epigastric discomfort ▪ Normal bowel opening ▪ Unable to tolerate fluid for past 1-2 days ▪ Attended AED yesterday & diagnosed as “GE”, ▪ Discharged home with Holopon Any further questions? History ▪ Vomitus: yellowish fluid, no coffee ground ▪ Vague epigastric pain with vomiting ▪ Pain free in between ▪ No recent travel and no clustering of cases ▪ History of appendicectomy 1 year ago ▪ No known drug allergy ▪ Clerical work, no smoking or drinking ▪ LMP 1 month ago Examination ▪ Fever 37.9oC, Dehydrated, Lethargic ▪ CVS: Tachycardia, Hypotensive ▪ Resp: AE equal, no added sound ▪ Abdomen ▪ Soft, Non tender, Bowel sound normal ▪ No organomegaly ▪ Grid-iron scar What is your Immediate Management? Immediate stabilization ▪ Shock! Resuscitation STAT! ▪ A, B - oxygen ▪ C - Immediate fluid replacement ▪ Treat underlying problem What type of shock is likely in this patient? Causes of Shock ▪ Hypovolemic ▪ Fluid loss ▪ Hemorrhagic ▪ Distributive ▪ Sepsis/SIRS ▪ Anaphylaxis ▪ Cardiogenic ▪ Myocarditis ▪ Myocardial infarction ▪ Obstructive ▪ Pulmonary Embolism ▪ Aortic Dissection ▪ Cardiac Tampanode What type of shock is likely in this patient? What TESTS would you like to do? Tests ▪ H’stix ▪ DKA ▪ Blood gases ▪ Acidosis – shock/sepsis/poisoning ▪ RLFT, Amylase ▪ Renal failure ▪ Hepatitis ▪ Pancreatitis ▪ Ultrasound ▪ Assessment of shock ▪ Urine ▪ Ketone ▪ Dehydration, DKA ▪ WBC, Nitrite ▪ Urosepsis ▪ Urobilinogen, Bilirubin ▪ Hepatitis, Biliary obstruction, Hemolytic disease ▪ Pregnancy Test ▪ Ectopic Pregnancy ▪ CBC ▪ WBC - Infection ▪ Hb - Hemorrhage blood lost ▪ Plt – Infection, DIC Imaging ▪ CXR ▪ Free gas under diaphragm ▪ Pneumonia ▪ Cardiomegaly (Myocarditis) ▪ AXR ▪ Intestinal obstruction ▪ Gastric dilatation ▪ Gastroparesis in DM ▪ USG ▪ ECHO ▪ LV Contractility ▪ RV dilatation ▪ ▪ ▪ ▪ ▪ ▪ IVC collapse index Intra-abdominal free fluid Biliary sepsis/Liver abscess HCC/AAA Hydronephrosis Ectopic pregnancy ▪ Abnormal shadow ▪ Abscess ▪ Aerobilia ▪ Appendicolith ▪ CT brain ▪ Suspected increase ICP if headache/decreased GC and repeated vomiting The story continue... ▪ After fluid replacement BP 100/50, HR 100 ▪ Notice tingle of jaundice at sclera ▪ Urine multistix ▪ Urobilinogen 4+, Bilirubin 2+, Ketone 2+ ▪ H’stix 3.6 How to interpret the findings? What cause elevated Urobilinogen and Bilirubin? ↑ Urinary Urobilinogen ↑ Urinary Bilirubin ▪ Liver Disease ▪ Hemolytic disorder ▪ ▪ ▪ ▪ Testing Reagents p-dimethylaminobenzaldehyde Hepatitis Cirrhosis Other liver disorders Biliary obstruction Testing Reagents 2,4-dichloroaniline diazonium salt Urine Urobilinogen Urine Bilirubin Normal +++ Liver damage ++ + or - Hemolytic disease +++ Negative Bile duct obstruction What next? Bilirubin ALT AST ALP GGT INR WBC 360 μmol/l 6150 IU/L 5650 IU/L 190 IU/L 20 IU/L 3.8 15 x 109/L Diagnosis ▪ Acute Liver Failure likely diagnosis - Clinical manifestation of sudden and severe hepatic injury ▪ Fulminant Hepatic Failure ▪ First used in 1970 ▪ Potentially reversible disorder that was result of severe liver injury with onset of encephalopathy within 8 weeks of symptom in the absence of pre-existing liver disease ▪ In young children, encephalopathy could be absent or late What is the likely cause at this point? Clinical Features ▪ General ▪ SIRS ▪ Hyper-metabolic status ▪ Liver ▪ ▪ ▪ ▪ ↓Gluconeogensis – HypoG ↓Lactate clearance – Lactic acidosis ↓NH3 clearance – ↑NH3 Coagulopathy ▪ Adrenal gland ▪ ↓Glucocorticoid - Hypotension ▪ Brain ▪ Encephalopathy ▪ Cerebral edema ▪ ↑ICP ▪ Kidney ▪ Lung ▪ ALI, ARDS ▪ Frequently AKI Acute Liver Failure Hyper-acute Acute Subacute 0-1 week 1-4 weeks 4-12 weeks +++ ++ + Severity of jaundice + ++ +++ Degree of intracranial hypertension ++ ++ +/- Good Moderate Poor Paracetamol Hepatitis A Hepatitis E Hepatitis B Nonparacetamol drug induced liver injury Time from jaundice to Encephalopathy Severity of coagulopathy Survival rate without emergency liver transplant Typical cause ▪ Causes – wide geographical variation ▪ Developing world – Hepatitis A, B, E accounting for most cases ▪ Developed world – Drug induced liver injury ▪ In Hong Kong / SE Asia ▪ High prevalence of Hepatitis B infection Acute Liver Failure – Viral Hepatitis HAV HBV HCV HDV HEV 0.01%-0.1% 1.0% Very rare Co: 1%-10% Super: 5%-20% Pregnant: 20% Risk factors for ALF HBV, HCV Age>40 IVDA Alcohol Females HCV HBV Chronic HBV Pregnancy Clinical course Hyperacute Acute Subacute Acute Hyperacute Spontaneous survival after ALF 40-60% 15-39% IgM-anti HAV IgM-anti HBc HBsAg HBV DNA Risk of ALF Diagnostic test 31-45% Anti-HCV HCV RNA IgM-anti HDV IgM-anti HBc IgM-anti HEV Co: Co-infection; Super: Superimposed infection of chronic HBV Viral Hepatitis ▪ Aminotransferase sensitive but not specific ▪ AST: Mitochondria 80%, Cytosol 20% ▪ Liver, Heart, Skeletal muscle, Kidney, Brain, Pancreas, Lungs, RBC ▪ ALT: Only in Cytosol ▪ Outcome may not be correlated to degree of elevation ▪ Elevation greater than 10 times ▪ Associated extensive hepatocellular damage ▪ esp. in severe viral hepatitis, drug/toxin induced, ischemic ▪ AST:ALT<1: Viral hepatitis ▪ AST:ALT>1: Chronic liver injury ▪ Lack of elevation in ALT ? Pyridoxine deficiency ▪ AST:ALT>2: Alcoholic liver disease (seldom > 500 IU/L) The story continue... ▪ Patient did not have history of hepatitis ▪ Previous body check revealed ▪ HBsAb +ve ▪ HBsAg –ve ▪ No recent travel ▪ Improper cooked seafood intake What are the other causes of ALF? Drug induced ALF ▪ Paracetamol overdose ▪ The most common cause ▪ Liver transaminase ▪ Rise within 12 to 24 hours post ingestion ▪ Peaking AST > ALT ▪ Significantly higher than for other cause of ALF ▪ Usually observed 3 days post ingestion ▪ Peak bilirubin levels are lower than for other causes ▪ Spontaneous survival rate is higher Usually idiosyncratic reaction Non-dose dependence More sub-acute clinical course The story continue... ▪ Patient did not have any depressed mood or suicidal ideation ▪ Not on any chronic medications What are the other causes of ALF? Other causes of ALF ▪ Biological toxin ▪ Toxic Mushroom (Amanita phallodies, verna and virosa) ▪ Delay onset of vomiting ▪ Traditional herbal medication ▪ Diagnosis by exclusion ▪ Examples: 黃藥子(黃獨), 蒼耳子,望江南子(豬屎豆),雷公藤,蜈蚣粉,千里光,天 花粉,川楝子,川楝皮,苦楝皮,補骨脂(破故紙),何首烏 + most of 31 scheduled 1 herbs ▪ Metabolic causes ▪ Acute Wilson disease ▪ Acute fatty liver of pregnancy, HELLP ▪ Autoimmune hepatitis ▪ Ischemic ▪ Shock liver, Budd-Chiari syndrome/Sinusoidal obstruction syndrome The story continue... ▪ Patient has recent consumption of mushroom ▪ Found in country parks near the reservoirs ▪ Developed vomiting 6-8 hours after ingestion Amanita Phallodies induced ALF ALF Management ▪ Supportive care ▪ Multi-organ failure ▪ ICU for organ system support ▪ Underlying cause ▪ NAC ▪ Nucleotide analogue inhibitors ▪ MDAC, Penicillin, Silibinin - Paracetamol overdose - Hepatitis B - Amanita poisoning Liver Transplantation ▪ King’s college criteria ▪ Paracetamol ▪ pH<7.3 or HE 3 +, Cr 300 + ▪ INR 6.5 ▪ Non-Paracetamol ▪ HE + INR 6.5+ ▪ Or Any THREE ▪ INR 3.5 + ▪ Bil 300 + ▪ Age<10 or >40 ▪ Unfavorable cause ▪ Clinically acceptable for specificity ▪ Survival without transplantation < 15% ▪ Sensitivity might be low ▪ However, so far no other criteria has shown consistent and reproducibly better performance Learning Point ▪ Vomiting + Diarrhea NOT ALWAYS GE ▪ Interpretation of Urine Urobilinogen/Bilirubin ▪ Interpretation of deranged LFT ▪ Look for precipitating cause of Acute Liver Failure ▪ Specific treatments may alternate outcome of patient End THANK YOU
