6min chapter

Your Mom's House with Christina P. and Tom Segura cover image

667 - Bobby Lee & Khalyla Kuhn- Your Mom's House with Christina P and Tom Segura

Your Mom's House with Christina P. and Tom Segura

CHAPTER

What if Lus Account Doesn't Exist?

I've been doing these stupid wires, avenmo apsta, ac pete ye, credit cards. Remember how horrible it was to have to carry a cheque book around always and then go the grocery store? And we like also the fact that you could, at least once write a check that you didn't have the amount for,. eh, oh, i have, accidentally, obviously. Right? But, like, people could write cheques. What if lus account doesn't exist? Yes, what an interesting thing we all did right now. It's like, onor system. Send that thing through the phone. I never knew how much money i had on my bank account

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Speaker 2
The same go for the alpha 1 anti-tripsin, the Wilson's. Those are the less common or rare, I guess in this case of Wilson's rare things. And in a patient that's presenting acutely like this one, that doesn't alpha 1 anti-tripsin without also not be something that would present acutely.
Speaker 1
Precisely. Right. So alpha 1 anti-tripsin cannot present acutely. And when it does present with liver disease, it's usually the people with alpha 1 anti-tripsin who present with elevated liver enzymes typically have risk factors for things like fatty liver disease. Like alpha 1 anti-tripsin is like kindling for fatty liver disease. If you look at it across national databases, that's the kind of person who presents for care because of elevated liver enzymes. So again, the only test that are not going to give you an answer at all are iron tests. And alpha 1 anti-tripsin, cerebral plasma testing for Wilson disease might give you an answer you don't want as it's often positive. But the thing you don't want to sleep on is billy-ary obstruction. Right.
Speaker 2
So, yeah, with the billy-ary obstruction, I would commonly, I've seen this many times now where person comes in, often the left pain, the enzymes are in the several hundreds. I haven't seen them as often in the thousands, but then like the next morning they've like come drastically down and the patient feels better, looks better. And you know, even if you don't see a stone, in some cases, that's my assumption is that it was a stone.
Speaker 1
I think that's a great assumption as you have a stone that is either passed or is ball valving up and down the duct with transient obstruction that gets relieved as it refluxes back up. And so my strategy when I see that kind of thing is sometimes those stones are super small is I have, I do the blood tests when the patient has pain. So they come to see me after the primary care doctor has seen elevated liver enzymes. The enzymes are normal. And then I say here, just call me when you have pain, we check the labs. Boom, if you have pain and elevated liver enzymes, you have a very good clinical diagnosis of colodocalosis. And
Speaker 4
Ellie, can you speak to how warmed up in these cases of acute liver injury where you have an AST of 1900 and the ALT of 1010? Like how excited should we get about the ratio of one to the other? Does that matter so much? I feel like it would be easy to anchor on like alcohol use, even though this patient sort of declines history is because of the specific ratio. Like is that something we're paying a lot of attention to in the acute setting or does it not matter so much or is it toxin specific?
Speaker 1
Yeah, I appreciate you bringing this up because people do, they remember the ratio of AST to ALT where it is said that those with alcoholic hepatitis have a ratio of AST to ALT that's like two to one. But alcohol creates a relatively low level of elevated liver enzymes compared to this. So if the AST plus ALT is less than 500, then you can suspect alcohol related liver disease. But if it's greater than that, the odds that this is being caused by alcohol is super low. And I don't exactly know why, but once the ALT or AST is over a thousand, that breakdown is way out the door. There's probably differences in clearance of AST and synthesis of ALT that it's happening when the liver is jacked up like this. I don't particularly know, but I can tell you for certain that the ratio means nothing when you have massively elevated liver enzymes like
Speaker 2
this. Because we're suspecting for Ms. Dilly, a drug-induced liver injury, she was recently on nitrofyr and telin. We went to the ACP conference recently and Paul had brought one of the pearls he brought back was that certain drugs have like a signature to them. And one of those signatures can be like an autoimmune hepatitis type picture. If nitrofyr and telin is one of those, what would you expect when you order the ANA, the anti-smooth muscle antibody, the IgG pattern? What would a positive, what would it look like on a typical basis when you're getting that back? Yeah.
Speaker 1
So there are a couple of drugs that are known to be associated with autoimmune hepatitis. Trophyr and telin is one of them. Minus cycling is a classic one. And you do see the classic pattern of positive tests for autoimmune hepatitis in many of those cases, which is to say a very large titer in ANA. So it's not just going to be like one to 80. It's going to be very long. You're going to have flagrantly positive smooth muscle antibody. So not just one to 20, but greater than one to 80. And the IgG is not going to be like 1,000 or 1,500 like borderline positive. It will be several fold that when you have full blown autoimmune hepatitis. But I'll tell you that in my practice, I have diagnosed autoimmune hepatitis very rarely meeting criteria using those serologic markers. Oftentimes if I'm worried about autoimmune hepatitis, I've gotten a liver biopsy. And I always get a liver biopsy before starting something like prednisone. So we'll talk about this maybe, but usually with drug induced liver injury, it just gets better, particularly one that is not presenting with elevated bilirubin or alkaline phosphatase. But if it's not getting better and you're thinking about liver biopsy, you're really asking the question, is this drug an environmental exposure that has set off autoimmune hepatitis?
Speaker 2
When you withdraw, like she's been off the drug for two weeks, how long would you expect it to go back to normal for drug induced liver injury? And is it different if it's an autoimmune type than just another just direct toxic type? Yeah.
Speaker 1
So the short answer is there's no particular cookbook answer to how long this lasts. So depending on the height of the elevated liver enzymes or my concern about the patient, I'm usually checking these labs somewhat frequently, like once a week until I have established the trend over time. And once I'm more comfortable with the trajectory, then I start to peel back. And I have seen it take a couple of years to completely normalize drug induced liver injury of this sort. And if it's not normalizing, then we have a discussion about pulling the trigger on liver biopsy because I'm not just going to use steroids willy nilly. Okay.
Speaker 2
Yeah. This is unfamiliar territory for me. This is fantastic. I, Elena, is there more to this case? Are we going to let Miss Dilly off the hook here? Is she going to get better? What's happening?
Speaker 3
Yeah. I think not completely relevant to her, but I think it's also helpful to think about what defines drug induced liver injury. So in her, it's pretty clear that she has this liver injury. And her biggest risk factor was this recent nitrofure into. It looks like the rest of her labs came back negative. Like her hepatitis labs were negative or HIV was negative, which I don't know if we mentioned that one, but her A&A was negative. And so really it comes back to drug induced liver injury and just thinking about how would you define this? And if her liver tests weren't quite so elevated, when would you think about stopping a medication if it was just a slight elevation versus continuing the medication?
Speaker 1
Well, the definition of drug induced liver injury is something that you are free to make in your own clinic. If you see someone who you've known for a while, positive liver enzymes after you've started a medication, even if that doesn't rise to the level that would be included in an official international case series for drug, for Dilly, then that's okay. So typically, when you see these consortia that have compiled the lists of usual offenders for Dilly, they're including patients who've had an elevated ALT that's greater than five times the upper limit of normal or something that is two times the upper limit of normal for alkaline phosphatase or some combination between the two. That generally forms the denominator. But if your patient barely meets that, it's okay for you to stop a medicine and see what happens. The truth is that things like statins are often started in people who have risk factors for non-alcoholic fatty liver disease, and that is a condition where the liver enzymes can go up and then go down. And so if you are checking the labs frequently, you might see elevated liver enzymes that will wane over time. The key here is how much higher have they gone? Do they rise to the level of true concern before you stop a medicine that might have significant benefits?
Speaker 2
All right. So we're saying this patient, Elena, so we're saying she did not have the autoimmune pattern on her labs. We really didn't find anything. We just know she had this exposure. So we can make a presumptive diagnosis that this was a drug-induced liver injury. And in that case, other than stopping the drug, Elliot, is there anything else that we need to do? No.
Speaker 1
And this is a case where less is more. It's often thought that you could help by giving something like prednisone. It doesn't help. If there's an elevated alkylophosphatase, you'll see many people in the hepatology sphere give something like erso-dial, and that may or may not change the labs. It certainly doesn't help the natural history. If they're starting to have complications of the drug-induced liver injury, like they have severe cold stasis and itching, it's totally rare. It's reasonable to try things to help with that cold stasis. Erso-dial might help. And then you'll see us use other supportive care for that itch, things like cold styramine. And that's about it.
Speaker 2
So we have some more cases to get into. I wanted to just ask one follow-up question because part of the desire for doing this show is to, of course, learn how to interpret these. But also I want to know which labs should we and shouldn't we be ordering? And a lot of the times there's these liver, kidney, micro-zone, and it seems like there's a little bit of an expanded paddle that goes along with the autoimmune. You gave us a pretty simplified ANA, anti-smooth muscle antibody, and the IgG, which is the same as what the guidelines say. Where do these other tests come from and is it ever helpful for us to be ordering them? Yeah.
Speaker 1
So the anti-liver kidney, microzoma one, is something that's going to be typically elevated in autoimmune hepatitis that's associated with young children. There's another test that I have ordered from time to time where I see seronegative autoimmune hepatitis in middle-aged women called the soluble liver antigen. They are almost never positive. Now if you run a specialist clinic for autoimmune hepatitis, you'll definitely see this because you're testing this more frequently. But at the end of the day, I need to manage the patient. And if I'm going to be worried about autoimmune hepatitis, I'm going to go with a liver biopsy. And there's nothing about those other serologic tests that would change my decision making. So you'll see me using the most standard tests, rarely using other tests, and going based on histology for clinical decision making.
Speaker 2
Fantastic.

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