Hepatic emergencies

A podcast and show notes from FOAM was linked here at EM Basic.

A few points and questions of interest raised in the post:

Do abnormal coags preclude paracentesis?

It's controversial and ultimately boils down to an assessment of benefit versus risk. Some authorities give a relative contraindication when the INR is greater than 2. Others emphasize clinical bleeding risk (clinical evidence of DIC or fibrinolysis) over laboratory values. Similar controversy exists regarding whether to give blood products in an attempt to reverse coagulopathy prior to paracentesis.

SBP prophylaxis in cirrhotic patients with upper GI bleeding

Some evidence suggests a NNT for mortality of 22 according to the notes.

Is ammonia measurement helpful in diagnosing and monitoring hepatic encephalopathy?

The discussants say categorically no. I think that position is a little extreme, in that controversy surrounds the question. There are data showing that the level of ammonia correlates with the presence or absence of HE and with its severity, even if the correlation is poor. There are caveats in using blood ammonia, and when patients present altered they need a thorough work up even if the ammonia is very high.

Amoxicillin-clavulanate is high on the list of drugs that cause liver injury

This was news to me but per the pod cast and notes the NIH reports it as number one, believed to be due to the clavulanate component. It is a mixed hepatocellular and cholestatic pattern.


And for some more pearls, particularly the interpretation of lab values in liver emergencies, see the slides and lecture notes by Nick Genes linked here. (Note: the acuity classification for liver failure seems to get tweaked just about every time I see a liver talk, and Nick's is no exception).