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Drug-induced Toxic Hepatitis

Toxic or Drug Induced Hepatitis


Presentation

  • Included in the great number of agents known to be able to cause this type of hepatitis are common drugs and chemicals It is seen in up to 30 percent of patients who present with acute hepatitis and represents up to 10 percent of consultations by hepatologists[medicscientist.com]
  • Patients often present with fever, abdominal pain, and jaundice. Multiple serum lab values are often elevated, including AST, ALT, and GGT.[radiopaedia.org]
  • Younger patients present most commonly with a hepatocellular pattern of injury, whereas older patients mostly present with a cholestatic pattern of liver injury. 3 Some studies have found that women have a greater risk of developing DILI than men. 13[mdedge.com]
  • Always consider drugs as a cause of any patient presenting with hepatitis in order to provide early effective management.[patient.info]
  • We present a 26-year-old male bodybuilder who self-administered high doses of androgenic/anabolic steroids that induced liver damage.[ncbi.nlm.nih.gov]
Fever
  • If fever, rash, or pruritis occurs from any medication, its use should be stopped immediately.[hepatitiscentral.com]
  • More common in children Cholestatic type Idiosyncratic reaction Nausea, vomiting, fever, RUQ pain, jaundice, leukocytosis, elevated aminotransferases Clinical improvement upon drug withdrawal No evidence of CLD on follow up 19.[slideshare.net]
  • Drugs causing hypersensitivity reactions (eg, penicillin and procainamide) may be associated with fever, rash, and peripheral eosinophilia.[medicscientist.com]
  • A rash or fever may be part of some drug reactions that affect the liver. Treatment The only specific treatment for most cases of liver damage caused by taking a drug is to stop the drug that caused the problem.[m.ufhealth.org]
  • Other viral infections - eg, glandular fever, cytomegalovirus, HIV infection. Autoimmune hepatitis. Wilson's disease, haemochromatosis. Toxins - eg, alcoholic liver disease.[patient.info]
Gastric Lavage
  • Supportive measures Gastric lavage Activated charcoal or cholestyramine (prevent absorption); should be given within 30 mins N-acetylcysteine given within 8 hrs; loading dose-140/kg, ff by 70mg/kg q 4 hrs x 15-20 doses Survivors have no evidence of hepatic[slideshare.net]
  • Paracetamol poisoning is treated with gastric lavage and N-acetyl cystine which reduces hepatic necrosis, if therapy is started within 8 hours of ingestion. The main treatment for DILI is withdrawal of the offending drug[medicscientist.com]
Jaundice
  • Combination of estrogenic and progestational steroids; estrogen is primarily responsible Intrahepatic cholestasis Pruritus and jaundice Susceptible patients: idiopathic jaundice of pregnancy, family history Focal nodular hyperplasia, adenomas 20.[slideshare.net]
  • Such sensitization would have been evident during the second postoperative week, with such manifestations as fever, rash, eosinophilia, arthralgia, or jaundice.[hepatitiscentral.com]
  • Viral hepatitis Acute hepatitis with jaundice can be the onset manifestation of acute viral hepatitis.[nature.com]
  • Others may have Loss of appetite Nausea and vomiting Diarrhea Dark-colored urine and pale bowel movements Stomach pain Jaundice, yellowing of skin and eyes Some forms of hepatitis are mild, and others can be serious.[icdlist.com]
  • The signs and symptoms of Drug-Induced Hepatitis resemble those of viral hepatitis and may include: Jaundice or yellowing of the skin and eye whites Jaundice may lead to pruritus, an intense itching sensation all over the body Nausea and vomiting White[dovemed.com]
Scleral Icterus
  • Patient 1 On July 16, 1992, a 42-year-old man visited his family physician for evaluation of scleral icterus and diffuse jaundice.[cdc.gov]
Dark Urine
  • Later, there may be jaundice and dark urine and an enlarged and tender liver. When the offending medication is withdrawn, symptoms may gradually subside. Reactions may be severe, however, and even fatal, even though the medication is stopped.[hepatitiscentral.com]
  • Some of the common symptoms are: nausea vomiting headache anorexia jaundice clay color stools dark urine hepatomegaly Diagnosis Diagnosis is typically made through a physical exam along with a patient history to identify any possible hepatotoxins.[medical-dictionary.thefreedictionary.com]
  • urine Diarrhea Fatigue Fever Headache Jaundice Loss of appetite Nausea and vomiting Rash White or clay-colored stools Exams and Tests You will have blood tests to check liver function.[m.ufhealth.org]
  • Later, overt evidence of liver damage, such as jaundice, dark urine and an enlarged and tender liver, may develop. Two general pathogenic mechanisms are recognised: Predictable or direct: usually promptly follows an exposure to a new medication.[patient.info]

Treatment

  • The main treatment for DILI is withdrawal of the offending drug[medicscientist.com]
  • Obtaining a history of exposure to hepatotoxic chemicals, medications, or other agents assists in early initiation of treatment and removal of the offending agent.[hepatitiscentral.com]
  • Reichen J: Treatment of cholestasis. Semin Liv Dis 13:302–315, 1993 Google Scholar 23.[link.springer.com]
  • Treatment There is no specific treatment for hepatitis A. The doctor will recommend the abstinence of alcohol and drugs during recovery. Most cases of hepatitis A resolve themselves spontaneously.[healthcentral.com]
  • Treatment There isn't any specific treatment other than immediate discontinuance of the causative agent. Rest during the acute phase of the disease is vital along with the intake of fluids to maintain hydration.[medical-dictionary.thefreedictionary.com]

Prognosis

  • What is the Prognosis of Drug-Induced Hepatitis? (Outcomes/Resolutions) The prognosis of Drug-Induced Hepatitis is usually good.[dovemed.com]
  • Treatment and prognosis Treatment depends on the etiology of the acute hepatitis.[radiopaedia.org]
  • Prognosis Usually the symptoms will go away after the drug has been eliminated due to the liver repairing itself. A full recovery is typically expected unless it wasn't treated quickly resulting in more liver damage being done than normal.[medical-dictionary.thefreedictionary.com]
  • Prognosis is good. Notice the presence of fine yellow granular bile pigment in the cytoplasm of hepatocytes around the central vein (zone 3).[meddean.luc.edu]
  • JCO. 2002, 20:2789-2797 Mavros MN, Mayo SC, Hyder O, Pawlik TM A systematic review treatment and prognosis of patients with fibrolamellar hepatocellular carcinoma.[ivyunion.org]

Etiology

  • Etiologies may include: viral hepatitides: (e.g.[radiopaedia.org]
  • […] drug exposure varies from hours to months Clinical manifestations range from asymptomatic deranged liver function to fulminant hepatic failure and death Mimic all forms of acute, chronic, vascular or neoplastic liver diseases that are caused by other etiologies[pathologyoutlines.com]
  • Keywords Primary Biliary Cirrhosis Autoimmune Hepatitis Reference Interval Antimitochondrial Antibody Histocompatibility Leukocyte Antigen Introduction The etiology of autoimmune hepatitis (AIH) is unknown.[jmedicalcasereports.biomedcentral.com]
  • (Etiology) Drug-Induced Hepatitis is caused by certain types of drugs, which include: Amiodarone Anabolic steroids Birth control pills Erythromycin General anesthetic halothane Methotrexate Sulfa antibiotics The exact mechanism of how these drugs lead[dovemed.com]
  • […] the CIOMS/RUCAM scale. 3,32,43 Electronic files of these causality-assessment tools are available on the LiverTox website. 44 The clinical practice guidelines on DILI advise that consensus expert opinion (following a thorough evaluation of possible etiologies[uspharmacist.com]

Epidemiology

  • Hepatotoxicity of Herbals and Dietary Supplements Introduction Epidemiology of and Expenditure on Herbals and Dietary Supplements Origin and Production of Herbals and Botanicals for Medicinal Purposes Regulation of Dietary Supplements The Use of Herbal[elsevier.com]
  • About 10% of cases are idiosyncratic. [ 1 ] Epidemiology A very large number of drugs have been implicated as a potential cause of drug-induced hepatitis but with variable risk of both frequency and severity.[patient.info]
  • Epidemiology of idiosyncratic drug-induced liver injury. Semin Liver Dis. 2009;29:337-347. 5. Larson AM. Drug-induced liver injury. UptoDate. www.uptodate.com/contents/drug-induced-liver-injury. Accessed July 8, 2016. 6.[uspharmacist.com]
Sex distribution
Age distribution

Pathophysiology

  • Definition / general Drug / toxin reactions can be intrinsic or predictable, where they are dose dependent (e.g. acetaminophen ); or idiosyncratic and unpredictable, where they are dose independent (e.g. isoniazid) Pathophysiology Underlying mechanisms[pathologyoutlines.com]
  • Oxidant Stress, Antioxidant Defense, and Liver Injury Introduction The Major Reactive Oxygen and Nitrogen Species in the Liver and their Sources Pathophysiological Consequences of Oxidative Stress Antioxidants Drug-Induced Oxidative Stress in the Liver[elsevier.com]
  • Review article: drug-induced liver injury—its pathophysiology and evolving diagnostic tools. Aliment Pharmacol Ther. 2011;34:11-20. 36. Roy PK. Budd-Chiari syndrome. Medscape. . Accessed August 31, 2016. 37. Gilroy RK. Wilson disease. Medscape. .[uspharmacist.com]

Prevention

  • Supportive measures Gastric lavage Activated charcoal or cholestyramine (prevent absorption); should be given within 30 mins N-acetylcysteine given within 8 hrs; loading dose-140/kg, ff by 70mg/kg q 4 hrs x 15-20 doses Survivors have no evidence of hepatic[slideshare.net]
  • To prevent hepatitis D: Since the hepatitis D virus cannot infect on its own without hepatitis B, use the preventive measures outlined in hepatitis B. To prevent hepatitis E, remember to: Wash hands well after using any washroom.[healthcentral.com]
  • Monitoring for and recognition of drug-induced hepatotoxicity may prevent some cases of acute hepatic failure.[nejm.org]
  • Vaccines can help prevent some viral forms.[icdlist.com]
  • Preventing Liver Damage There are many different things you can do in order to prevent liver damage. Be mindful of the following tips 5, 7 : Don’t take more than the recommended dose of acetaminophen or other non-prescription medications.[drugabuse.com]

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