Drug induced liver injury

Intrinsic (dose related)Idiosyncrasy (not dose dependent)
CCl4, acetaminophen, MTX, phosphorusIsoniazid, halothane, phenytoin

Symptoms- Fever, skin rash, eosinophilia

Hy’s law- ALT or AST>3 fold, total bilirubin>2 fold, no other reason of liver injury→ fulfill these 3 criteria mortality rate=10%


Hepatitis patternCholestatic patternMixed pattern
ALT>=3 ULN, R value >=5ALP>=2 ULN, R value<=2ALT>3 ULN, ALP>=2 ULN, 2 < R value < 5
Isoniazid, rifampin, statin, halothaneAugmentin, anabolic steroid, estrogen, erythromycinPhenytoin, sulfonamide, nicotinic acid

R value=(ALT/ULN)/(ALK-P/ULN)

Diagnosis- Positive re-challenge and de-challenge, RUCAM score

Alcoholic liver disease

Risk factor- >80g daily for >5 years, female, protein malnutrition

Lab- AST/ALT>2~3, AST, ALT rarely >300. elevated Alk-p and GGT

Maddrey’s discriminant function- >32→ mortality >50%→  Used corticosteroid but without GI bleeding, infection, renal failure

Pathology- Mallory body(Prekeratin intermediate filaments)

Complication- Variceal hemorrhage, coagulopathy and thrombocytopenia, hepatic encephalopathy, iron overload, ascites, SBP

Treatment- Quit alcoholing, nitrogen intake, >2000Kcal/day, protein 1g/kg

*Maddrey’s discriminant function= [4.6x(PT patient – PT control) + total bilirubin]


Foreword- Hepatic steatosis(NAFL)(>5% fat in liver)→  Steatohepatitis(NASH)(lobular inflammation)


Insulin resistanceMedicationNutritionalLiver disease
Obesity, Type 2 DMGlucocorticoid, estrogen, tamoxifen, amiodaroneStarvation, Kwashiorkor, choline deficiencyWilson, Chronic hepatitis, C-genotype 3, Jejunoileal bypass. Indian childhood cirrhosis


NAFLD fibrosis score

a)Age, BMI, diabetes, AST, ALT, platelet, serum albumin

b)<-1.455(F0~F2), >0.675(F3~F4)

Treatment- Treat DM, loss weight, lifestyle modification, assessed cardiovascular risk

Autoimmune hepatitis(AIH)


Type I (75~85%)Type IIa (<5%)Type IIb (<5%)Type III (<10%)
ANA, ASMA (Ig G anti-F-actin)Anti-LKMAnti-LKM Anti-soluble liver antigen, ASMA
Young and middle aged womenChildren and young womenOlder men and womenYoung and middle
Autoimmune thyroiditis, RA
Associated with HCV

Biopsy- Portal triad with plasma cell

Monotherapy- Predisolone 30~60 mg/day

Combination therapy- Prednisolone 30mg/kg + azathioprine 50mg/day

Published by Steve Johnson

I am a doctor who like to organise knowledges and share ideas with others. As a doctor, a lot of knowledges influx everyday and need some patient to organise and absorb. Here was my notes to share with you and hope to save your time to know it.

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