Specimen Name Result Units Range
Plasma Sodium 142 mmol/L (135-145)
Potassium 4.3 mmol/L (3.5-5.5)
Chloride 97 mmol/L (100-109)
Bicarbonate 29 mmol/L (22-32)
Anion Gap 20 mmol/L (7-17)
Glucose 4.1 mmol/L (3.8-5.5)
Urea 4.2 mmol/L (2.7-7.2)
Creatinine 120 μmol/L (60-110)
Osmolality 279 mmol/kg (275-295)
Urate 0.33 mmol/L (0.20-0.40)
Phosphate 1.30 mmol/L (0.80-1.45)
Total Calcium 2.40 mmol/L (2.10-2.55)
Albumin 45 g/L (34-48)
Globulins 26 g/L (22-35)
Total Bilirubin 64 μmol/L (6-24)
Conj. Bilirubin 42 μmol/L (1-4)
GGT 298 U/L (< 60)
ALP 208 U/L (30-110)
AST 17,800 U/L (< 45)
LDH 13,425 U/L (110-230)
Cholesterol 3.4 mmol/L (3.5-5.5)

27yo male with history of chronic headaches & ETOH abuse.
Paracetamol & Alcohol Hepatic Necrosis
  • Plasma [paracetamol] = 120U/L
  • Profound elevation of ASL (+LDH)
  • High HCO3- suggests pre-existing metabolic alkalosis ∝ ETOH

Elevation of AST:

  • alcoholic hepatitis : 30-300 (median ≈ 120)
  • acute viral hepatitis : 100-3300 (median ≈ 650)
  • alcohol+paracetamol : 2000-31000 (median ≈ 6900)

Pathogenesis:

  • primary metabolism by the liver ≈ 85%:
    1. glucuronidation ≈ 55%
    2. sulphation ≈ 30% → both excreted by the kidney
    3. P450 MFO ≈ 5-8% → N-acetyl-p-benzoquinoneimine (NAPQI)
  • increased susceptibility to toxicity with,
    1. overdose & saturation of normal conjugation
    2. hepatic glutathione depletion*
    3. induction of P450 MFO system*
  • NB: *both of the later occur in chronic alcoholism
    → potential toxicity with chronic "≈ normal" usage

Clinical Features:

  • nausea & vomiting
  • abdominal pain & tenderness
  • pallor
  • coma - unusual, unless other drugs or late presentation
  • liver dysfunction → late, usually ≥ 24 hours
  • non-treated above "treatment line"
    • ≈ 60% → severe liver damage at 3-5 days
    • ≈ 5% → hepatic failure, encepalopathy, coma & death
  • uncommon complications
    • renal failure - ATN ± papillary necrosis
    • cardiac failure
    • pancreatitis