Drug-Induced Liver Injury: What You Need to Know
Drug-Induced Liver Injury: What You Need to Know
The diagnosis of DILI is largely a process of exclusion of other causes of liver disease, coupled with a thoughtful history and physical examination that identify causative medications.
The ACG guidelines propose an algorithm defined by identification of suspected DILI as hepatocellular, cholestatic, or mixed hepatocellular/cholestatic liver injury, with a differential diagnosis and clinical judgment that establish the final diagnosis.
Individuals with suspected hepatocellular or mixed hepatocellular/cholestatic liver injury should be evaluated for acute viral hepatitis caused by HBV and other nonhepatotropic viruses (cytomegalovirus, Epstein-Barr virus, herpes simplex), and for autoimmune hepatitis and other forms of acute liver injury, such as Budd-Chiari syndrome and Wilson disease. Remember that Wilson disease typically presents as acute liver injury before the age of 25 years, although it can present later in life. Routine testing for HEV in patients with suspected DILI is not currently recommended.
Patients with cholestatic liver injury should be evaluated with ultrasonography to exclude primary biliary cirrhosis, and with cholangiography as needed for suspected stones, strictures, or tumors.
The guidelines also recommend consideration of liver biopsy for patients with possible autoimmune hepatitis or when abnormal liver tests fail to resolve promptly.
Patients with suspected DILI should stop taking offending medications, and NAC can be administered to adults with acute liver failure. Reexposure to a drug suspected of causing DILI is discouraged.
Take-Away Points
The diagnosis of DILI is largely a process of exclusion of other causes of liver disease, coupled with a thoughtful history and physical examination that identify causative medications.
The ACG guidelines propose an algorithm defined by identification of suspected DILI as hepatocellular, cholestatic, or mixed hepatocellular/cholestatic liver injury, with a differential diagnosis and clinical judgment that establish the final diagnosis.
Individuals with suspected hepatocellular or mixed hepatocellular/cholestatic liver injury should be evaluated for acute viral hepatitis caused by HBV and other nonhepatotropic viruses (cytomegalovirus, Epstein-Barr virus, herpes simplex), and for autoimmune hepatitis and other forms of acute liver injury, such as Budd-Chiari syndrome and Wilson disease. Remember that Wilson disease typically presents as acute liver injury before the age of 25 years, although it can present later in life. Routine testing for HEV in patients with suspected DILI is not currently recommended.
Patients with cholestatic liver injury should be evaluated with ultrasonography to exclude primary biliary cirrhosis, and with cholangiography as needed for suspected stones, strictures, or tumors.
The guidelines also recommend consideration of liver biopsy for patients with possible autoimmune hepatitis or when abnormal liver tests fail to resolve promptly.
Patients with suspected DILI should stop taking offending medications, and NAC can be administered to adults with acute liver failure. Reexposure to a drug suspected of causing DILI is discouraged.
