Acute Liver Failure

Acute Liver Failure. Acute liver failureSudden and severe hepatocellular dysfunction (jaundice, coagulopathy, and encephalopathy) which develops in previously healthy individualsMortality ranges from 30-100 %Worldwide Causes of Acute Liver Failure.

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

Figure 3 Worldwide Causes of Acute Liver Failure. HAV denotes hepatitis A virus, HBV hepatitis B virus, HEV hepatitis E virus, and NT not tested.Acetaminophen toxicity more common in the US and UK. No data in Thailand but in Asian population are more common associated with viral hepatitis such as hepatitis E in India and hepatitis B in China and Japan.Case 1 PE: mark jaundice and not pale conjunctivaChest: no spider nevi, normal breath soundAbdomen: liver and spleen not palpable, negative for shifting dullnessExt: no edema, asterixis positiveInvestigationCBC: Hb 12.0, WBC 7000, Plt 150,000AST 500, ALT 450, ALK 130Direct bilirubin 20.0, Total Bilirubin 22.0INR 2.0Cr 1.0 Clinical Stages of Hepatic EncephalopathyImpairmentClinical StagesIntellectual FunctionNeuromuscular FunctionSubclinicalNormal Exam but work or driving may impairSubtle change on psychometric or number connection testStage 1Impair attention, irritability or personality changeTremor, incordination, apraxiaStage 2Drowsiness, poor memory, sleep disordersAsterixis, Slow or slur speechStage 3Confusion, disorientation, somnolesenceHypoactive reflex, nystagmus, clonusStage 4Stupor and comaDilated pupils, decerebrate, absence of response to stimuliSleisenger and Fordtrans. Gastrointestinal and liver diesease 8th (89) 1966STAGES OF HEPATIC ENCEPHALOPATHY

Confusion

DrowsinessSomnolenceComa1234StageStages of Hepatic Encephalopathy7Stage 1: mild changes in cognition, sleep wake cycleStage 2: asterixisStage 3: drowsiness but arousable with voice stimuliStage 4: comaHistory Risk factor for viral hepatitisAlcohol, toxinHerbal medicineMedication Substance abuse, over doseFamily history of liver diseases

InvestigationAnti HAV IgMHBsAg, Anti-HBc IgM Anti-HCVImaging ie. Ultrasound or CT scanOther test: Ceruloplasmin, ANA (Antinuclear antibody), ASMA (Antismoothmuscle Ab)Acetaminophen levelHBc IgG and Anti-HBs to confirm chronicity, check window period.HCV RNASpeaking in general then specific to this case later.9RESULTAnti-HAV IgMNegativeAnti-HAV IgGPositiveHBsAgPositiveAnti-HBc IgMNegativeAnti-HBsNegativeAnti-HCVNegativeAcetaminophen levelPendingRumack-Matthew nomogram10TreatmentAdmit and close monitorConscious levelRespirationLab coagulogram, blood glucoseAvoid excess stimulation, nephrotoxic drugs and NSAIDsIV fluid, nutrition supportAntibiotic prophylaxis (fever or coagulopathy)

Elevated head of bed to decrease ICPFrequency of blood test and conscious level, need ICU monitor and frequent visit by doctor.INR daily at most, or at evaluate or procedureFBS trend to drop then BID to QID Do not need to restrict protein, not chronic liver injury but should be around 1 mg/kg/day.12LactuloseNecessary? Nutritional supportEnteral or parenteral?Protein?Low salt?CoagulopathyCorrection?

Lactulose 13Paracetamol Overdose< 4 hr. consider gastric lavage and activated charcoalN-Acetylcystiene (NAC) IV or POInternal medicine/GI Consultation referral

Consider therapeutic treatment trail if result pending or can not send the test.Oral NAC 140 mg/kg loading then 70 mg/kg every 4 hr until total of 72 hr.14