44 year old man presents with severe Paracetamol toxicityDescribe and Interpret:
Deranged LFTs with normal Paracetamol level suggest established toxicity in the absence of another cause – (2-3 days)
Severe elevation in ALT – hepatocellular necrosis
Elevated INR, low Albumin – Impaired hepatic synthetic function
Evidence of end organ damage – abnormal renal function and liver function
Normal electrolytes
Clinical Phases of Paracetamol Toxicity:
| Phase 1
(<24 hours) |
Asymptomatic
Nausea, Vomiting |
| Phase 2
(1-3 days) |
RUQ tenderness
ALT/AST rise rapidly, peak at 48-72 hours, may reach 15000-20000 Hepatoxicity is ALT > 1000 INR/PT are most abnormal within hours of ALT/ AST peak Hyperbilirubinaemia Impaired renal function |
| Phase 3
3-4 days |
Fulminant hepatic failure – coagulopathy, jaundice, encephalopathy, multi organ failure, progressing to death
In patients who die: Lactic acidosis, elevated lactate despite resuscitation Renal failure (Creat > 300) Worsening coagulopathy (PT > 100 sec) and encephalopathy |
| Phase 4
4 days-3 weeks |
Recovery phase
Hepatic structure and function return to normal |