Acute Liver Failure

Acute liver failure

Sudden and severe hepatocellular
dysfunction (jaundice, coagulopathy, and
encephalopathy) which develops in
previously healthy individuals
Mortality ranges from 30-100 %

Worldwide Causes of Acute Liver Failure.

Bernal W, Wendon J. N Engl J Med 2013;369:2525-2534

Case 1

PE: mark jaundice and not pale conjunctiva

Chest: no spider nevi, normal breath sound
Abdomen: liver and spleen not palpable,
negative for shifting dullness
Ext: no edema, asterixis positive

Investigation
CBC: Hb 12.0, WBC 7000, Plt 150,000
AST 500, ALT 450, ALK 130
Direct bilirubin 20.0, Total Bilirubin 22.0
INR 2.0
Cr 1.0

Clinical Stages of Hepatic Encephalopathy

Impairment
Clinical
Stages

Intellectual Function

Neuromuscular Function

Subclinical

Normal Exam but work or

driving may impair

Subtle change on
psychometric or
number connection test

Impair attention, irritability or

Tremor, incordination,

personality change

apraxia
Asterixis, Slow or

Stage 1
Stage 2

Drowsiness, poor memory,

Stage 3

sleep disorders
Confusion, disorientation,
somnolesence

Stage 4

Stupor and

coma

slur speech
Hypoactive reflex,
nystagmus, clonus
Dilated pupils,
decerebrate, absence of
response to stimuli

Sleisenger and Fordtrans.

Gastrointestinal and liver diesease 8th
(89) 1966

STAGES OF HEPATIC ENCEPHALOPATHY

Stages of Hepatic Encephalopathy

Confusion
Confusion

Drowsiness
Drowsiness

Somnolence
Coma
Coma
11

22

Stage

33

44

History
Risk factor for viral hepatitis
Alcohol, toxin
Herbal medicine
Medication
Substance abuse, over dose
Family history of liver diseases

Investigation
Anti HAV IgM
HBsAg, Anti-HBc IgM
Anti-HCV
Imaging ie. Ultrasound or CT scan
Other test: Ceruloplasmin, ANA
(Antinuclear antibody), ASMA
(Antismoothmuscle Ab)
Acetaminophen level

RESULT

Anti-HAV IgM

Negative

Anti-HAV IgG

Positive

HBsAg

Positive

Anti-HBc IgM

Negative

Anti-HBs

Negative

Anti-HCV

Negative

Acetaminophen level

Pending

Treatment


Admit and close monitor
Conscious level
Respiration
Lab coagulogram, blood glucose
Avoid excess stimulation, nephrotoxic drugs and
NSAIDs
IV fluid, nutrition support
Antibiotic prophylaxis (fever or coagulopathy)

 Lactulose
Necessary?

Nutritional support
Enteral or parenteral?
Protein?
Low salt?

Coagulopathy
Correction?


Paracetamol Overdose
< 4 hr. consider gastric lavage and activated
charcoal
N-Acetylcystiene (NAC) IV or PO
Internal medicine/GI Consultation referral