General Data

AW

16 yo

Female

Roman Catholic

Cordova Cebu

Admitted for the 1st time in UCMed

Chief Complaint

● Epigastric Pain
Prenatal, Natal, Postnatal History

● Born to a G1P0 34 yr old mother with unremarkable maternal history

● Delivered full term via NSD at a hospital in Zamboanga attended by MD.
● No perinatal complications
● Postnatal history-unremarkable
Immunization

● Completed with AP
Past medical history

● No previous surgeries
● 2004- admitted at Zamboanga (Measles)
● Non-asthmatic
● Non-diabetic
● Non-hypertensive
● Allergies: Shrimps
Personal History

● Patient lives with her parents and with

her sister.
● She is a senior high student.
History of Present Illness
● 8 days PTA, patient had sudden onset of intermittent fever with Tmax 38.9 associated with
headache, body malaise, anorexia, and vomiting x 2 episodes around 5 tbsp per episode. No
cough, no coryza, no loose bowel movement, no abdominal pain. Patient took Paracetamol
1 tab every 4 hours even without fever.
● 6 days PTA, fever still persisted with Tmax of 38.8, still associated with body malaise,
epigastric pain stabbing in character, vomiting, and anorexia. No alteration in bowel
movement. Sought consult with AP and labs were ordered: CBC 105/61/5.9/389 18/41/7/4/0,
UA was not done since patient had her period, Dengue test showed negative result. No
medications were given.
● 5 days PTA, fever persisted. Patient had sudden onset of epigastric pain with pain score of
10/10. Sought consult at ARC. UA was done showing Blood 2+/Ketones 2+/ RBC 6-10, WBC
0-3; managed as UTI. She was given Pantoprazole 40 mg OD, Co-amoxiclav 625 mg bid
(only took one dose) and PCM 500mg Q4h prn for fever.
History of Present Illness
● 4 days PTA, there was lysis of fever. Abdominal pain recurred with the same pain score
10/10, stabbing in character. She also had onset of chest pain pressure-like with pain score
of 10/10 associated with difficulty breathing. She was subsequently admitted in ARC and
managed as T/C ACS, UTI.
● At ARC, O2 supplementation was started. Lab tests were performed.
Labs and Imaging tests done at ARC

Blood tests done at ARC Blood tests done at ARC

● ABG: Ph 7.551, PCO2 22.2, PO2 221.4, ● Anti-HCV NR

HCO3 19.7, SaO2 99 ● HAV IgG NEG
● Trop I- <0.01 ● HAV IgM neg
● ECG SR NSTWC ● HbsAg 0
● ASO <25 ● Anti-HBs positive
● ESR 12 ● Alkaline phosphatase 3.55 (0.65-2.14)
● ALT 864 (7-35) repeat 1018 ● Amylase 52
● Lipase 40.07
 Labs and Imaging tests done at ARC
VIRUSES BACTERIA
Adenovirus Not detected Bordatella parapertussis Not detected
Coronavirus 229E Not detected (IS1001) Not detected
Coronavirus HKU1 Not detected Bordatella pertussis Not detected
Coronavirus NL63 Not detected (ptxP)
Coronavirus OC43 Not detected Chlamydia pneumoniae Not detected
SARS-CoV2 RT PCR Not detected Mycoplasma pneumoniae Not detected
Human Metapneumovirus Not detected
Human rhinovirus/enterovirus Not detected
Influenza A Not detected SARS CoV 2 Rapid Test
Influenza B Not detected
Parainfluenza 1 Not detected Covid 19 IgM Negative
Parainfluenza 2 Not detected
Parainfluenza 3 Not detected Covid 19 IgG Negative
Parainfluenza 4 Not detected
RSV Not detected
Imaging tests done at ARC

Imaging tests done at ARC Imaging tests done at ARC

● ECG SR NSTWC ● Chest X-Ray: Normal chest

● 2D-Echo- Normal; EF 69%
● UTZ WA-Unremarkable UTZ of the
liver, gall bladder, pancreas, spleen,
aorta/paraaortic region, kidenys,
urinary bladder and uterus
 History of Present Illness

● At ARC, the patient was admitted and started on O2 supplementation via face mask
● The patient was started on Cefuroxime 500mg 1 tab BID PO, Pantoprazole 40mg IVTT, Tramadol Hcl
50mg IVTT, Sucralfate ½ tab (500mg) 4x a day and NAC 900 mg + D5W 30ml via syringe pump to give
in 30 mins q6h (received NAC IV infusion for 1 1/2 days). The patient opted to transfer here in UCMed
(per patient’s choice).
 Physical Examination
● General: awake, conscious, coherent, cooperative, NIRD
● Vital signs: T 36.8, PR 74 BPM, RR 20 cpm, O2 sat 100%
● Skin: warm, good turgor, no jaundice, no skin lesions
● HEENT: AIS, PPC, neck supple with no LAD
● C/L: ECE, CBS, no rales, no wheeze
● CVS: DHS, RRR, no murmur
● Abdomen: flat, NABS, (+ )tenderness to palpation at the epigastric and RUQ area, no
hepatomegaly, liver is palpable 1 fingerbreadth below the subcostal margin
● Extremities: warm, SPP, CRT less than 2 s
Impression

● Toxic Liver Disease

● Non-Ulcer Dyspepsia
● Hyperventilation Syndrome
At the ER …
● Admitted
● Diet: Hypoallergenic diet
● ISA inserted
● Medications:
○ Cefuroxime 500mg 1 tab q12h PO for 3 more days
○ Pantoprazole 40 mg IVTT once daily
○ Sucralfate 1 gram/tablet ½ tab 4x a day PO (6A,11A,4P,10P)
○ NAC 100mg/ml ampule, 900mg(9ml) + 30ml D5W IV via syringe pump to give in 30mins
q6h
○ Vital signs monitored q4h
 DAY 1-2
S O A P

No complaints of Vs: T 36.8, HR 100, Toxic Liver Disease Continued on NAC IV

epigastric and right RR 21, BP 100/60 Non-ulcer dyspepsia drip, Sucralfate and
upper quadrant pain. Abdomen: flat, NABS, Hyperventilation Pantoprazole
No vomiting. soft, + tenderness at Syndrome
the epigastric area and
right upper quadrant
area upon palpation
with pain score of 5/10.
 DAY 3
S O A P

No complaints of Vs: T 36.5, HR 83, RR Toxic Liver Disease Continued on NAC IV

epigastric and right 20, BP 100/70 Non-ulcer dyspepsia drip, Sucralfate and
upper quadrant pain. Abdomen: flat, NABS, Hyperventilation Pantoprazole
No vomiting. soft, + tenderness at Syndrome
the epigastric area and
right upper quadrant
area upon palpation
with pain score of 3/10.
 Urinalysis
Color Yellow
Day 3 Clear
Ph 7.5
S.G 1.010
Protein Negative
Glucose Negative
Ketones Negative
Blood Negative
Urobilinogen Normal
Nitrite Negative
Leukocyte Esterase Trace
Bilirubin Negative
RBC 0-2
WBC 2-5
Epithelial cells Rare
Mucus threads Rare
Bacteria Moderate
 DAY 4-6
S O A P

No complaints of Vs: T 36.5, HR 83, RR Toxic Liver Disease Received 23 doses of

epigastric and right 20, BP 100/70 Non-ulcer dyspepsia NAC IV infusion.
upper quadrant pain. Abdomen: flat, NABS, Hyperventilation Cleared for discharge
No vomiting. soft, + tenderness at the Syndrome With the following take
epigastric area with pain home medications:
score of 2/10. no Pantoprazole 40 mg/tab
tenderness at the RUQ 1 tab once daily for 3
area. weeks
Sucralfate 1gm/tab ½
SGPT- 245⇨160 tab 4x a day for 2 weeks
Aptt- 42.2/32.4 more.
Protime-
12.5/12/85%/1.09
CXR APL: Unremarkable
Thoracolumbar APL-
Mild thoracic
dextroscoliosis with mild
compensatory lumbar
levoscoliosis
TOXIC LIVER
DISEASE
Acetaminophen Toxicity

● Acetaminophen (APAP) is the most widely used analgesic and antipyretic in pediatrics, available in
multiple formulations, strengths, and combinations.
● It is commonly available in the home, where it can be unintentionally ingested by young children, taken
in an intentional overdose by adolescents and adults, or inappropriately dosed in all ages.
Pathophysiology

● Results from the formation of a highly reactive intermediate metabolite, N-acetyl-p-benzoquinone

imine (NAPQI).
● In therapeutic use, only a small percentage of a dose (approximately 5%) is metabolized by the
hepatic cytochrome P450 enzyme CYP2E1 to NAPQI, which is then immediately joined with
glutathione to form a nontoxic mercapturic acid conjugate.
● In overdose, glutathione stores are overwhelmed, and free NAPQI is able to combine with hepatic
macromolecules to produce hepatocellular necrosis.
● The single acute toxic dose of APAP is generally considered to be >200 mg/kg in children and
>7.5-10 g in adolescents and adults.
Clinical and Laboratory Manifestations
Treatment
1. Prophylactic.
● If the APAP level is known and the ingestion is within 24 hr
of the level being drawn, treatment decisions are based on
where the level falls on the Rumack-Matthew nomogram
● This nomogram is only intended for use in patients who
present within 24 hr of a single acute APAP ingestion with
a known time of ingestion.
● The importance of instituting therapy with either IV or oral
NAC no later than 8 hr from the time of ingestion cannot
be overemphasized.
● No patient, regardless of the size of the ingestion, who
receives NAC within 8 hr of overdose should die from liver
failure.
Treatment

2. Hepatic Injury
Evidence of hepatocellular necrosis, manifested first as elevated liver transaminases (usually AST first,
then alanine transaminase [ALT]), followed by a rise in the INR.

3. Acute Liver Failure

King’s College criteria: acidemia (serum pH <7.3) after adequate fluid resuscitation, coagulopathy (INR
>6), renal dysfunction (creatinine >3.4 mg/dL), and grade III or IV hepatic encephalopathy (see Chapter
391). A serum lactic acid >3 mmol/L (after IV fluids) adds to both sensitivity and specificity of the
criteria to predict death without liver transplant. The degree of transaminase elevation does not factor in
to this decision-making process.
 Treatment

4. Repeated Supratherapeutic Ingestion

Rumack-Matthew nomogram is not helpful in this scenario.
Asymptomatic patient: if the AST is normal and the APAP is <10 μg/mL, no therapy is indicated.
A patient presenting with symptoms (i.e., right upper quadrant pain, vomiting, jaundice) should be empirically
started on NAC pending lab results.
 Treatment

The IV form is used in patients with intractable vomiting, those with evidence of hepatic failure, and pregnant
patients. Oral NAC has an unpleasant taste and smell and can be mixed in soft drink or fruit juice or given by NG
tube to improve tolerability of the oral regimen.

IV dosing delivers less medication to the liver compared with the oral regimen. As a result, many toxicologists now
recommend higher doses of the IV formulation in patients with large overdoses. Transaminases, synthetic function,
and renal function should be followed daily while the patient is being
treated with NAC.
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