Spotlight – Drug-Induced Liver Injury

STEP 1: Read this short case report online for free! It describes acute liver injury, for which iatrogenic causes should not be forgotten.

Loubster L, Weider K and Drake SM (2019). Acute Liver Injury induced by red yeast rice supplement. BMJ Case Reports. Published online First: [March 2019]. doi:10.1136/bcr-2018227961.

STEP 2: you are the Senior House Officer on call for the medical team. A 64-year-old female presents with a fortnight’s history of fatigue, bloating, dark urine and pale stools and a recent development of jaundice. How would you approach the history?

What findings might you expect on physical examination4?

Acute liver disease may be asymptomatic, or generalised (lethargy, jaundice, anorexia, malaise)- as with the patient in this case study.

Features of (chronic) liver disease that occur at later stages may be compensated (hepatomegaly, xanthelasmas, parotid enlargement, spider naevi, gynaecomastia, scratch marks) or decompensated (drowsy, hepatic flap, fetor hepaticus, ascites, oedema). These often occur at the later stages of disease progression.

What investigations would you request4?


The patient in this case study was given high dose intravenous methylprednisolone for 3 days, whilst causes (see investigations) were performed. She was then discharged on oral prednisolone.

Depending on the cause of the liver failure, treatment often involves lifestyle changes (alcohol cessation), good nutrition, pruritis relief (cholestyramine). If the patient has advanced disease such as ascites, fluid restriction and low salt diet may help.

Complications like hepatic failure (coagulopathy, confusion, sepsis, spontaneous bacterial peritonitis) need to be treated promptly. Liver transplantation remains the only definitive treatment for cirrhosis.