The Temporal Profile of Increased Transaminase Levels in Patients With Acetaminophen-Induced Liver Dysfunction,☆☆,

Presented in part at the North American Conngress of Clinical Toxicology, Salt Lake City, September 1994.
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Abstract

Study objective: It is often taught that acetaminophen-induced liver dysfunction occurs only after a latent period of 24 to 48 hours. This study was designed to evaluate the temporal profile of transaminase levels in patients with acetaminophen-induced hepatotoxicity.

Design: Prospective data collection using standard poison control center data sheets. Participants: Hospitalized patients with acetaminophen exposure who were reported to the Long Island Poison Control Center between January 1993 and June 1994. Patients who presented within 24 hours of ingestion and in whom increased aspartate aminotransferase (AST) levels developed during hospitalization were included in the data analysis. Patients who presented more than 24 hours after ingestion, who had ingested another potentially hepatotoxic agent, or who had ingested acetaminophen over a period of more than 2 hours were excluded. Results: Of 1,825 patients with reported acetaminophen exposure, 779 had potentially toxic ingestions and were examined in an emergency department. Of 291 patients with toxic acetaminophen levels who were admitted, 36 (12%) had increased levels of AST at some point during hospitalization. All received oral N -acetylcysteine within 2.5 hours of presentation. In 11 of 19 patients who met all inclusion criteria (58%), AST levels were noted to be increased in the 24 hours after ingestion. The median peak AST level was 422 IU/L (range, 74 to 8,538 IU/L). AST levels peaked within 48 hours in 4 patients (21%) and within 72 hours in 18 patients (95%). Six of eight patients with peak AST levels greater than 1,000 IU/L had increased transaminase levels during the 24 hours after acetaminophen ingestion. Conclusion: Acetaminophen poisoning may cause the serum transaminase level to increase during the 24 hours after ingestion. [Singer AJ, Carracio TR, Mofenson HC: The temporal profile of increased transaminase levels in patients with acetaminophen-induced liver dysfunction. Ann Emerg Med July 1995;26:49-53.]

Section snippets

INTRODUCTION

Acetaminophen is the single most common cause of poisoning requiring hospital admission and medical management.1 Although serum levels of the hepatic transaminases correlate poorly with ultimate outcome, they are often used to identify liver dysfunction in acetaminophen overdose.2, 3 Acetaminophen overdose has been characterized by an initial stage of gastrointestinal irritation followed by a latent stage lasting 24 to 48 hours before increase of transaminase levels.4 Hepatic transaminases peak

MATERIALS AND METHODS

We prospectively collected data on all hospitalized patients with acetaminophen overdose whose cases were reported to the Long Island Poison Control Center (LIPCC) between January 1993 and June 1994. Data included age, sex, ingestant, estimated amount of ingestant, estimated time of ingestion, coingestants, and pertinent information about the patient's medical history and medications. We used standard LIPCC data sheets to record data. During the study period, all LIPCC personnel were informed

RESULTS

During the study period, 1,825 cases of acetaminophen exposure were reported. Of this total, 779 patients had ingested potentially toxic amounts and were seen in an ED. Two hundred ninety-one of these patients had acetaminophen levels in the toxic range, and they were admitted. Increased serum transaminase levels developed during hospitalization in 36 patients; each had received the standard oral loading dose of N-acetylcysteine followed by 17 maintenance doses. Of the 36 patients, only 19 met

DISCUSSION

Acetaminophen is the most commonly reported potentially toxic ingestant in children and in adults. In 1992, 102,043 cases of acetaminophen ingestion were reported to poison centers in the United States, of which 44,876 were evaluated in a health care facility.1 Acetaminophen toxicity has been divided into various stages.4, 10 After an initial stage of gastrointestinal irritation, a latent phase of 24 to 48 hours elapses before serum hepatic transaminase levels increase. Transaminase levels then

CONCLUSION

Our findings suggest that acetaminophen poisoning may cause serum transaminase levels to increase within 24 hours and to peak within 48 to 72 hours of ingestion. It should not be assumed that patients with acetaminophen overdose who present with increased transaminase levels have ingested acetaminophen more than 24 hours earlier. Therefore they may still benefit from treatment with acetylcysteine.

Acknowledgements

The authors thank Judd E Hollander, MD, for reviewing this manuscript and for his helpful comments.

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From the Department of Emergency Medicine, University Medical Center, State University of New York, Stony Brook*; and the Long Island Regional Poison Control Center, Winthrop University Hospital, Mineola, New York.

☆☆

Address for reprints: Adam J Singer, MD, Department of Emergency Medicine, University Hospital, Room L4-515, State University of New York, Stony Brook, New York 11794-7400, 516-444-2499, Fax 516-444-3919

Reprint no. 47/1/65740

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