Back to Mild to Moderate Aminotransferase Elevation

Introduction

Most exogenous chemicals are processed by the liver. Similar to drug-induced liver injury, illicit drugs and toxins can cause either direct hepatotoxicity or idiosyncratic reactions.

History

Detailed history is crucial in the diagnosis. Illicit drugs are often "cut" with various chemicals. Additionally, cocaine can cause acute hepatitis and a history of recent cocaine use should always be investigated in a patient with acute hepatitis. Food (certain mushrooms), nutritional supplement and herbal remedies are potential sources of hepatotoxins. An 'outbreak' pattern may also provide a vital clue for an environmental or occupational exposure.

Physical examination

There are no specific signs for illicit drugs/toxin induced liver injury. Jaundice may be present. However, it is crucial to check for signs of potential liver synthetic dysfunction such as asterixis (encephalopathy) and ecchymosis (coagulopathy).

Patients who develop encephalopathy (confusion/asterixis) should be urgently referred to a liver specialist or a transplant center.

In acute hepatocellular injury, the presence of asterixis (encephalopathy) and coagulopathy defines acute liver failure. Patients should be urgently referred to liver specialists.

Laboratory investigation

• Toxicology screen
• PT/INR

Patients who develop coagulopathy (prolonged PT/INR) need to be monitored closely and should be urgently referred to liver specialists.