acute liver failure tutorial

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Acute liver Acute liver failure failure Tutorial Tutorial Ayman Abdo Ayman Abdo MD, FRCPC MD, FRCPC

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Acute liver failure Tutorial. Ayman Abdo MD, FRCPC. Objectives. After the discussion in this educational exercise, I want you to be able to : Identify common causes of acute liver failure through history and examination Recognize common presentations Be familiar with medical management - PowerPoint PPT Presentation

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Page 1: Acute liver failure Tutorial

Acute liver failureAcute liver failureTutorialTutorial

Ayman Abdo Ayman Abdo MD, FRCPCMD, FRCPC

Page 2: Acute liver failure Tutorial

ObjectivesObjectives

After the discussion in this educational After the discussion in this educational exercise, I want you to be able to :exercise, I want you to be able to :

Identify common causes of acute liver failure Identify common causes of acute liver failure through history and examinationthrough history and examination

Recognize common presentationsRecognize common presentations

Be familiar with medical managementBe familiar with medical management

Know when to refer a patient for Know when to refer a patient for transplantationtransplantation

Page 3: Acute liver failure Tutorial
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Acute Liver FailureAcute Liver FailureDefinitionDefinition

1.1. Rapid hepatocellular Rapid hepatocellular dysfunctiondysfunction

2.2. Encephalopathy Encephalopathy

3.3. No pre-existing liver No pre-existing liver diseasedisease

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Common causes of acute liver failureCommon causes of acute liver failure

Viral hepatitis: Hep A, Hep BViral hepatitis: Hep A, Hep B

Toxin/drugToxin/drug

IschemicIschemic

Autoimmune hepatitisAutoimmune hepatitis

Wilson disease Wilson disease

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Pt 1: Initial historyPt 1: Initial history

66 y old female66 y old female

Chronic abdominal pain and constipationChronic abdominal pain and constipation

Otherwise healthyOtherwise healthy

3 day history of jaundice and confusion3 day history of jaundice and confusion

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Patient 1Patient 1

What other questions What other questions are you going to ask?are you going to ask?

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Important questions on historyImportant questions on history

Recent travelRecent travelSexual exposureSexual exposureIVDUIVDUContact with jaundiced ptContact with jaundiced ptDetailed drug history including herbsDetailed drug history including herbsAutoimmune featuresAutoimmune featuresNeurological symptomsNeurological symptomsRecent hypotension or sepsesRecent hypotension or sepses

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Pt 1 : More historyPt 1 : More history

Dx to have IBSDx to have IBS

Started on herbal medication 1 week agoStarted on herbal medication 1 week ago

No viral hepatitis risk factorsNo viral hepatitis risk factors

No hypercoagulable disorderNo hypercoagulable disorder

No new medicationsNo new medications

Page 10: Acute liver failure Tutorial

Patient 1Patient 1

What physical signs are What physical signs are you going to look for?you going to look for?

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Physical examinationPhysical examination

Vital signsVital signs

Level of concisenessLevel of conciseness

Flapping tremorFlapping tremor

Stigmata of chronic liver diseaseStigmata of chronic liver disease

Ophthalmology exam if indicatedOphthalmology exam if indicated

Full abdominal examinationFull abdominal examination

Full neurological examinationFull neurological examination

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Patient 1Patient 1

What labs are you going What labs are you going to order?to order?

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Important labsImportant labs

CBC and electrolytesCBC and electrolytesLiver enzymes : ALT, AST, ALP, GGT, LDHLiver enzymes : ALT, AST, ALP, GGT, LDHLiver function tests: INR, Albumine, BiliLiver function tests: INR, Albumine, BiliViral hep serology= HAV IgM, Hep B cAb IgM, Viral hep serology= HAV IgM, Hep B cAb IgM, HCV RNAHCV RNAToxic screen: Acetaminophen levelToxic screen: Acetaminophen levelAIH markers: ANA, ASMAAIH markers: ANA, ASMAWilson: Ceruloplasmin, urine cupperWilson: Ceruloplasmin, urine cupperOthersOthers

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Causes of acute liver failureCauses of acute liver failure

Viral hepatitis: Hep A, Hep BViral hepatitis: Hep A, Hep B

Toxin/drugToxin/drug

IschemicIschemic

Autoimmune hepatitisAutoimmune hepatitis

Wilson disease Wilson disease

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Lab investigationsLab investigations

CBCCBC

ElectrolytesElectrolytes

Liver enzymes (ALT, AST, ALP, GGT, LDH)Liver enzymes (ALT, AST, ALP, GGT, LDH)

Liver function tests (Bili, Albumin, INR)Liver function tests (Bili, Albumin, INR)

Hep A (IgM, IgG), Hep B (HBsAG, HBcIgM)Hep A (IgM, IgG), Hep B (HBsAG, HBcIgM)

Acetaminophen levelAcetaminophen level

ANAANA

Cerulopasmin, 24 h copper collectionCerulopasmin, 24 h copper collection

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Pattern in Ischemic hepatitisPattern in Ischemic hepatitis

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Ischemic vs. viralIschemic vs. viral

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Get more information ?Get more information ?

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ComplicationsComplications&&

ManagementManagement

Page 23: Acute liver failure Tutorial
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Specific therapySpecific therapy

Viral:Viral:

Ischemic:Ischemic:

Toxic: Toxic:

Acetaminophen (N-acetyl cystein)Acetaminophen (N-acetyl cystein)

AutoimmuneAutoimmune

WilsonWilson

Page 25: Acute liver failure Tutorial

Which pt will recover with Which pt will recover with intensive medical therapy and intensive medical therapy and

which pt requires which pt requires transplantation?transplantation?

Page 26: Acute liver failure Tutorial

King’s College CriteriaKing’s College Criteria

AcetaminophenAcetaminophen

pH < 7.3pH < 7.3

oror

Grade III or IV HE Grade III or IV HE andand– INR > 6.5INR > 6.5– Creatinine > 300Creatinine > 300

Non-acetaminophenNon-acetaminophenINR > 6.5INR > 6.5or any 3/6or any 3/6– AAge <10 or >40 yrsge <10 or >40 yrs– BBili > 300ili > 300– CCoagulopathy: INR > 3.5oagulopathy: INR > 3.5– DDuration of jaundice uration of jaundice

> 7 days before HE> 7 days before HE– EEtiology: Non A-E, other drugtiology: Non A-E, other drug

O’Grady et al. Gastroenterology 1989;97:439

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MARS : Molecular adsorbents recycling system

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More quick casesMore quick cases

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Case 2Case 2

A 33 y old femaleA 33 y old female

Just came back from UmrahJust came back from Umrah

Has 2 day history of dark urine and yellow Has 2 day history of dark urine and yellow eyeseyes

No new medicationsNo new medications

Page 33: Acute liver failure Tutorial

Patient 2Patient 2

What are the possible What are the possible causes of this causes of this presentation?presentation?

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Case 2Case 2

No physical signs except for jaundiceNo physical signs except for jaundice

No encephalopathyNo encephalopathy

ALT=2300, AST=1700, ALP=480, ALT=2300, AST=1700, ALP=480, GGT=789, INR=2.1GGT=789, INR=2.1

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Patient 2Patient 2

How would you manage How would you manage this patient?this patient?

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Patient 3Patient 3

55 y old male 55 y old male

Massive acute MIMassive acute MI

Successful resuscitationSuccessful resuscitation

Cardiac condition stableCardiac condition stable

5 days later: ALT=2300, AST=2000, 5 days later: ALT=2300, AST=2000, LDH=4500LDH=4500

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Patient 3Patient 3

What is the most likely What is the most likely cause?cause?

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Patient 3Patient 3

How would you manage How would you manage this patient?this patient?

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Patient 4Patient 4

22 y old male22 y old male

Previously healthyPreviously healthy

1 week history of jaundice 1 week history of jaundice

ALT=1500, AST=3400, ALP=450, INR=1.8ALT=1500, AST=3400, ALP=450, INR=1.8

CBC= HB=7.8, WBC=10.8, PLt=340CBC= HB=7.8, WBC=10.8, PLt=340

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Patient 4Patient 4

What is the most likely What is the most likely cause?cause?

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Patient 4Patient 4

Cerulopasmin= very lowCerulopasmin= very low

24 urinary cupper= very high24 urinary cupper= very high

Ophthalmology exam= KFROphthalmology exam= KFR

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ConclusionConclusion

The most important three causes of acute liver The most important three causes of acute liver failure are : viral hepatitis, toxic hepatitis, and failure are : viral hepatitis, toxic hepatitis, and ischemic hepatitisischemic hepatitis

Less likely causes include: Autoimmune Less likely causes include: Autoimmune hepatitis, Wilson disease, malignant infiltrationhepatitis, Wilson disease, malignant infiltration

Early recognition and treatment of the causeEarly recognition and treatment of the cause

Medical management of complicationMedical management of complication

Decide early about transplantationDecide early about transplantation

Page 43: Acute liver failure Tutorial