Difference between revisions of "Drug-induced liver disease"

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#redirect [[Medical liver disease#Drug-induced liver disease]]
'''Drug-induced liver disease''', also '''drug-induced liver toxicity''', is relatively common.
 
Drug reactions in general are dealt with in ''[[drug toxicity]]''.
 
==General==
*Drugs can do almost anything; may include: [[granulomata]], bile duct loss, cholestasis, ischemic type injury.
*Effects can be delayed -- temporal relationship not always obvious.
 
==Microscopic==
Features:
*Non-specific findings.
**+/-Eosinophils<ref>{{Ref DCHH|166}}</ref> - '''significant suggestive finding'''.
**+/-Steatosis - periportal macrovesicular, microvesicular.
**+/-[[Vanishing bile duct syndrome]].
**+/-[[Granuloma]]s.
 
===Images===
<gallery>
Image:Drug-induced_hepatitis_low_mag.jpg | Drug-induced hepatitis - low mag. (WC)
Image:Drug-induced_hepatitis_intermed_mag.jpg | Drug-induced hepatitis - intermed. mag. (WC)
Image:Drug-induced hepatitis high mag.jpg | Drug-induced hepatitis - high mag. (WC)
</gallery>
 
===Specific patterns===
Acute hepatits:
*Related to Rx - most often antibiotics.
 
[[Steatohepatitis]]/[[steatosis]]:<ref name=pmid16237810>{{Cite journal  | last1 = Grieco | first1 = A. | last2 = Forgione | first2 = A. | last3 = Miele | first3 = L. | last4 = Vero | first4 = V. | last5 = Greco | first5 = AV. | last6 = Gasbarrini | first6 = A. | last7 = Gasbarrini | first7 = G. | title = Fatty liver and drugs. | journal = Eur Rev Med Pharmacol Sci | volume = 9 | issue = 5 | pages = 261-3 | month =  | year =  | doi =  | PMID = 16237810 }}</ref>
*Amiodarone - cardiac arrhythmias.
*Tamoxifen - [[breast cancer]].
*Carbamazepine - seizures.
 
[[Cholestasis]]:
*Venlafaxine - depression.<ref name=pmid23073329>{{Cite journal  | last1 = Stadlmann | first1 = S. | last2 = Portmann | first2 = S. | last3 = Tschopp | first3 = S. | last4 = Terracciano | first4 = LM. | title = Venlafaxine-induced cholestatic hepatitis: case report and review of literature. | journal = Am J Surg Pathol | volume = 36 | issue = 11 | pages = 1724-8 | month = Nov | year = 2012 | doi = 10.1097/PAS.0b013e31826af296 | PMID = 23073329 }}</ref>
*Thalidomide - [[multiple myeloma]].<ref name=pmid22789729>{{Cite journal  | last1 = Vilas-Boas | first1 = F. | last2 = Gonçalves | first2 = R. | last3 = Sobrinho Simões | first3 = M. | last4 = Lopes | first4 = J. | last5 = Macedo | first5 = G. | title = Thalidomide-induced acute cholestatic hepatitis: case report and review of the literature. | journal = Gastroenterol Hepatol | volume = 35 | issue = 8 | pages = 560-6 | month = Oct | year = 2012 | doi = 10.1016/j.gastrohep.2012.05.007 | PMID = 22789729 }}</ref>
 
===Specific drugs===
Acetaminophen:
*Zone 3 necrosis.
**Tx: N-acetylcysteine (NAC).<ref name=pmid19621836>{{cite journal |author=Millea PJ |title=N-acetylcysteine: multiple clinical applications |journal=Am Fam Physician |volume=80 |issue=3 |pages=265–9 |year=2009 |month=August |pmid=19621836 |doi= |url=}}</ref>
***NAC is an endogenous precursor to glutathione.<ref>URL: [http://www.mskcc.org/mskcc/html/69310.cfm http://www.mskcc.org/mskcc/html/69310.cfm]. Accessed on: 19 October 2010.</ref>
**Hepatotoxicity from ''N-acetyl-p-benzoquinoneimine (NAPQI)'' due to depletion of ''glutathione''.<ref name=pmid19621836>{{cite journal |author=Millea PJ |title=N-acetylcysteine: multiple clinical applications |journal=Am Fam Physician |volume=80 |issue=3 |pages=265–9 |year=2009 |month=August |pmid=19621836 |doi= |url=}}</ref>
 
Methotrexate - chronic use:
*Histology:<ref>{{Ref MacSween|715}}</ref>
**Features of steatohepatitis.
***Zone III steatosis.
***Ballooning degeneration.
**Portal inflammation with mixed population (lymphocytes, macrophages, PMNs).
**Nuclear atypia (hyperchromasia, pleomorphism, vacuolation).
***Described as just nuclear size variation by some.<ref>MG. 23 September 2009.</ref>
 
==Sign out==
<pre>
LIVER, MEDICAL CORE BIOPSIES:
- MILD STEATOHEPATITIS AND MILD FIBROSIS (1/4).
- MILD TO MODERATE STEATOSIS.
 
COMMENT:
The findings are compatible with nonalcoholic steatohepatitis (NASH), alcoholic
steatohepatitis (ASH) or drug effect. The steatosis is periportal predominant; this
is not typical for NASH or ASH. Clinical correlation and review of medications
is suggested.
</pre>
 
==See also==
*[[Medical liver disease]].
 
==References==
{{Reflist|2}}
 
==External links==
*[http://livertox.nih.gov Drug-liver toxicity (nih.gov)].
 
[[Category:Medical liver diseases]]

Revision as of 15:04, 5 September 2014

Drug-induced liver disease, also drug-induced liver toxicity, is relatively common.

Drug reactions in general are dealt with in drug toxicity.

General

  • Drugs can do almost anything; may include: granulomata, bile duct loss, cholestasis, ischemic type injury.
  • Effects can be delayed -- temporal relationship not always obvious.

Microscopic

Features:

Images

  • Drug-induced hepatitis - low mag. (WC)

  • Drug-induced hepatitis - intermed. mag. (WC)

  • Drug-induced hepatitis - high mag. (WC)

Specific patterns

Acute hepatits:

  • Related to Rx - most often antibiotics.

Steatohepatitis/steatosis:[2]

  • Amiodarone - cardiac arrhythmias.
  • Tamoxifen - breast cancer.
  • Carbamazepine - seizures.

Cholestasis:

Specific drugs

Acetaminophen:

  • Zone 3 necrosis.
    • Tx: N-acetylcysteine (NAC).[5]
      • NAC is an endogenous precursor to glutathione.[6]
    • Hepatotoxicity from N-acetyl-p-benzoquinoneimine (NAPQI) due to depletion of glutathione.[5]

Methotrexate - chronic use:

  • Histology:[7]
    • Features of steatohepatitis.
      • Zone III steatosis.
      • Ballooning degeneration.
    • Portal inflammation with mixed population (lymphocytes, macrophages, PMNs).
    • Nuclear atypia (hyperchromasia, pleomorphism, vacuolation).
      • Described as just nuclear size variation by some.[8]

Sign out

LIVER, MEDICAL CORE BIOPSIES:
- MILD STEATOHEPATITIS AND MILD FIBROSIS (1/4).
- MILD TO MODERATE STEATOSIS.

COMMENT:
The findings are compatible with nonalcoholic steatohepatitis (NASH), alcoholic
steatohepatitis (ASH) or drug effect. The steatosis is periportal predominant; this 
is not typical for NASH or ASH. Clinical correlation and review of medications 
is suggested.

See also

References

  1. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 166. ISBN 978-0470519035.
  2. ↑ Grieco, A.; Forgione, A.; Miele, L.; Vero, V.; Greco, AV.; Gasbarrini, A.; Gasbarrini, G.. "Fatty liver and drugs.". Eur Rev Med Pharmacol Sci 9 (5): 261-3. PMID 16237810.
  3. ↑ Stadlmann, S.; Portmann, S.; Tschopp, S.; Terracciano, LM. (Nov 2012). "Venlafaxine-induced cholestatic hepatitis: case report and review of literature.". Am J Surg Pathol 36 (11): 1724-8. doi:10.1097/PAS.0b013e31826af296. PMID 23073329.
  4. ↑ Vilas-Boas, F.; Gonçalves, R.; Sobrinho Simões, M.; Lopes, J.; Macedo, G. (Oct 2012). "Thalidomide-induced acute cholestatic hepatitis: case report and review of the literature.". Gastroenterol Hepatol 35 (8): 560-6. doi:10.1016/j.gastrohep.2012.05.007. PMID 22789729.
  5. ↑ 5.0 5.1 Millea PJ (August 2009). "N-acetylcysteine: multiple clinical applications". Am Fam Physician 80 (3): 265–9. PMID 19621836.
  6. ↑ URL: http://www.mskcc.org/mskcc/html/69310.cfm. Accessed on: 19 October 2010.
  7. ↑ Burt, Alastair D.;Portmann, Bernard C.;Ferrell, Linda D. (2006). MacSween's Pathology of the Liver (5th ed.). Churchill Livingstone. pp. 715. ISBN 978-0-443-10012-3.
  8. ↑ MG. 23 September 2009.

External links

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