Background

In the West, paracetamol overdose is the commonest cause of toxic hepatitis. It is not commonly recognized that ingestion of rat killer (yellow phosphorus) is the commonest cause of toxic hepatitis in Tamil Nadu. Documenting this will lead to increased awareness and steps to prevent / treat this problem in Tamil Nadu.

Methods

Retrospective study of the prevalence and causes of toxic hepatitis across Tamil Nadu – hospital based study.

Study Duration

6 months (January 2019 – June 2019)

Definition of toxic hepatitis

1. By Aetiology : acute hepatic dysfunction due to
   1. Overdose of a drug
   or
   
   2. ingestion of a toxin / poison
2. By Biochemistry : The degree of liver injury is to be classified into
   1. Uncomplicated acute hepatitis (ie. deranged LFT, INR ≤ 1.5)
   2. Acute liver injury / ALI (ie. deranged LFT and INR > 1.5)
   3. Acute liver failure / ALF (ie. ALI and hepatic encephalopathy)

   *Wendon J; et al. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. EASL. J Hepatol. 2017 May; 66 (5):1047-81.

Inclusion criteria

All patients who present with toxic hepatitis due to ingestion of a toxin (ex: rat killer) or due to overdose of a drug (ex: paracetamol) to be reported for inclusion in this study.

Exclusion criteria

Idiosyncratic drug induced liver injury (ie. liver injury occurring, while taking the correct dose of drug)

Other study variables

1. Initials of name (to prevent a patient who was treated in 2 hospitals from being counted twice in this study) / age / sex of patient
2. Date of alleged ingestion of toxin / drug overdose
3. Type of toxin ingestion : accidental / suicidal / homicidal
4. If suicidal intent, alleged reason for toxin ingestion : marital discord / exam stress / other
5. Name of toxin ingested or drug overdose (name. dose of drug) taken
6. Underlying psychiatric illness (ex: depression) : Yes / No
7. Prior suicide attempt
8. LFT results and no. of days after ingestion of the toxin / drug overdose
9. Viral serology results, if tested for : HBsAg, HCV ab, IgM HAV / IgM HEV ab
10. Other organs affected
11. Treatment
    1. In Emergency dept / Casualty.
    2. On admission to ICU / HDU / ward. Pharmacotherapy (please mention any particular drug used to treat), hemodialysis / hemofiltration, plasma exchange (PLEX), liver transplant.
12. Survival at end of hospital stay :

Discharged alive / died / underwent liver transplant / discharged in moribund state. Discharged home / referred to a higher centre for further treatment.

Expected outcome of the study

Rat killer (yellow phosphorus) induced hepatotoxicity is the commonest cause of toxic hepatitis in Tamil Nadu. It can be considered the “equivalent of paracetamol overdose induced hepatotoxicity” (seen in the West). Public health measures are needed to prevent / reduce this form of hepatotoxicity.