Objectives To identify common causes of acute liver failure through history and examination To recognize common presentations To be familiar with medical management To know when to refer a patient for transplantation
Common causes of acute liver failure Viral hepatitis: Hep A, Hep B Toxin/drugIschemic Autoimmune hepatitis Wilson disease
Pt 1: Initial history 66 y old female Chronic abdominal pain and constipation Otherwise healthy 3 day history of jaundice and confusion
Patient 1 What other questions are you going to ask?
Important questions on history Recent travel Sexual exposure IVDU Contact with jaundiced pt Detailed drug history including herbs Autoimmune features Neurological symptoms Recent hypotension or sepses
Pt 1 : More history Dx to have IBS Started on herbal medication 1 week ago No viral hepatitis risk factors No hypercoagulable disorder No new medications
Patient 1 What physical signs are you going to look for?
Physical examination Vital signs Level of conciseness Flapping tremor Stigmata of chronic liver disease Ophthalmology exam if indicated Full abdominal examination Full neurological examination
Lab investigations CBCElectrolytes Liver enzymes (ALT, AST, ALP, GGT, LDH) Liver function tests (Bili, Albumin, INR) Hep A (IgM, IgG), Hep B (HBsAG, HBcIgM) Acetaminophen level ANA Cerulopasmin, 24 h copper collection
Specific therapy Viral:Ischemic:Toxic: Acetaminophen (N-acetyl cystein) AutoimmuneWilson
Which pt will recover with intensive medical therapy and which pt requires transplantation?
King’s College Criteria Acetaminophen pH < 7.3 or Grade III or IV HE and –INR > 6.5 –Creatinine > 300 Non-acetaminophen INR > 6.5 or any 3/6 –Age 40 yrs –Bili > 300 –Coagulopathy: INR > 3.5 –Duration of jaundice > 7 days before HE –Etiology: Non A-E, other drug O’Grady et al. Gastroenterology 1989;97:439
Patient 4 Cerulopasmin= very low 24 urinary cupper= very high Ophthalmology exam= KFR
Conclusion The most important three causes of acute liver failure are : viral hepatitis, toxic hepatitis, and ischemic hepatitis Less likely causes include: Autoimmune hepatitis, Wilson disease, malignant infiltration Early recognition and treatment of the cause Medical management of complication Decide early about transplantation