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A woman with Vomiting

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

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A woman with Vomiting

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  1. HKCEM College Tutorial A woman with Vomiting Author Dr. E Yuen Revised by Dr. Wong Cheung Lun, William May 2013

  2. Triage Notes • Re-attend case • 43 years-old female • Repeated vomiting • BP 80/40 P140, RR 26 Triage Category II

  3. 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?

  4. 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

  5. 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

  6. What is your Immediate Management?

  7. Immediate stabilization • Shock! Resuscitation STAT! • A, B - oxygen • C - Immediate fluid replacement • Treat underlying problem What type of shock is likely in this patient?

  8. Causes of Shock • Cardiogenic • Myocarditis • Myocardial infarction • Obstructive • Pulmonary Embolism • Aortic Dissection • Cardiac Tampanode • Hypovolemic • Fluid loss • Hemorrhagic • Distributive • Sepsis/SIRS • Anaphylaxis What type of shock is likely in this patient?

  9. What TESTS would you like to do?

  10. Tests • 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 • H’stix • DKA • Blood gases • Acidosis – shock/sepsis/poisoning • RLFT, Amylase • Renal failure • Hepatitis • Pancreatitis • Ultrasound • Assessment of shock

  11. Imaging • USG • ECHO • LV Contractility • RV dilatation • IVC collapse index • Intra-abdominal free fluid • Biliary sepsis/Liver abscess • HCC/AAA • Hydronephrosis • Ectopic pregnancy • CT brain • Suspected increase ICP if headache/decreased GC and repeated vomiting • CXR • Free gas under diaphragm • Pneumonia • Cardiomegaly (Myocarditis) • AXR • Intestinal obstruction • Gastric dilatation • Gastroparesis in DM • Abnormal shadow • Abscess • Aerobilia • Appendicolith

  12. 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?

  13. What cause elevated Urobilinogen and Bilirubin? ↑ Urinary Bilirubin • Hepatitis • Cirrhosis • Other liver disorders • Biliary obstruction ↑ Urinary Urobilinogen • Liver Disease • Hemolytic disorder Testing Reagents p-dimethylaminobenzaldehyde Testing Reagents 2,4-dichloroaniline diazonium salt

  14. What next?

  15. 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?

  16. Clinical Features • Adrenal gland • ↓Glucocorticoid - Hypotension • Brain • Encephalopathy • Cerebral edema • ↑ICP • Kidney • Frequently AKI • General • SIRS • Hyper-metabolic status • Liver • ↓Gluconeogensis – HypoG • ↓Lactate clearance – Lactic acidosis • ↓NH3 clearance – ↑NH3 • Coagulopathy • Lung • ALI, ARDS

  17. Acute Liver Failure

  18. 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

  19. Acute Liver Failure – Viral Hepatitis Co: Co-infection; Super: Superimposed infection of chronic HBV

  20. 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)

  21. 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?

  22. 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

  23. Usually idiosyncratic reaction Non-dose dependence More sub-acute clinical course

  24. 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?

  25. 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

  26. 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

  27. ALF Management • Supportive care • Multi-organ failure • ICU for organ system support • Underlying cause • NAC - Paracetamol overdose • Nucleotide analogue inhibitors - Hepatitis B • MDAC, Penicillin, Silibinin - Amanita poisoning

  28. 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

  29. 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

  30. End Thank you

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