1
Acute liver failure Hepatic encephalopathy and coagulopathy within 12 to 26 wks of jaundice in a patient without preexisting liver disease
www.medicinemcq.com
www.medicinemcq.com 2
Acute viral hepatitis
Most common cause – 70 %
www.medicinemcq.com 3
Other causes
Amanita phalloides (mushroom) poisoning
Paracetamol toxicity – common in Europe and North America
Reye's syndrome Acute fatty liver of pregnancy Wilson's disease Shock Malignant disease of the liver
www.medicinemcq.com 4
HELLP Syndrome Hemolysis, Elevated Liver
enzymes, Low Platelets Severe, life-threatening
complication of PET Delivery - only known
treatment
www.medicinemcq.com 5
INVESTIGATIONS - cause
IgM anti-HBc IgM anti-HAV Anti-HCV, cytomegalovirus, herpes
simplex, Epstein-Barr virus Caeruloplasmin, serum copper, urinary
copper, slit-lamp eye examination Autoantibodies: ANA, ASMA, LKM Doppler ultrasound of liver
www.medicinemcq.com 6
COMPLICATIONS Encephalopathy and cerebral edema Hypoglycemia Metabolic acidosis Infection (bacterial, fungal) Renal failure Multi-organ failure (hypotension and
respiratory failure)
www.medicinemcq.com 7
Hepatic encephalopathy
Cerebral disturbance›Cardinal manifestation
www.medicinemcq.com 8
Ammonia Synthesized predominantly
› Gut microorganisms Detoxified in astrocytes to
osmotically active glutamine Contribute to
› Hepatic encephalopathy› Cerebral edema
www.medicinemcq.com 9
Hyperammonemia treatment
Lactulose Nonabsorbable oral antibiotics
www.medicinemcq.com 10
Cerebral edema
Causes intracranial hypertension
www.medicinemcq.com 11
Cytotoxic cerebral edema
Results from astrocyte swelling rather than a leaky blood brain barrier (vasogenic cerebral edema)
Corticosteroids are not recommended
www.medicinemcq.com 12
Manifestations
Decreasing consciousness Hyperventilation Systemic hypertension Pupillary abnormalities Decerebrate posturing, Uncal herniation and death
www.medicinemcq.com 13
ICP monitoring
Gold standard for measuring and monitoring ICH› < 25 mm Hg
Neuroimaging - not reliable in diagnosing early ICH› To exclude other problems (e.g.,
intracranial bleeding or stroke)
www.medicinemcq.com 14
ICP transducer
Requires correction of underlying coagulopathy
Portal of entry for infectious organisms
Can precipitate intracranial hemorrhage
www.medicinemcq.com 15
Mannitol First-line therapy for intracranial hypertension
Elevate head of the bed to 30 degrees
www.medicinemcq.com 16
Refractory cerebral edema
IV hypertonic saline
IV thiopental
www.medicinemcq.com 17
Hypothermia (e.g., 32° to 33°C)
External cooling blankets
In refractory cerebral edema
Require an ICP monitor
www.medicinemcq.com 18
Infection
Main cause of death in ALF
Signs - frequently absent
www.medicinemcq.com 19
Most common sites
Lung Urinary tract Blood
www.medicinemcq.com 20
Most common organisms
Gram-positive cocciStaphylococciStreptococci
Enteric GNB Candida
www.medicinemcq.com 21
Sedation Propofol and benzodiazepines
are most commonly used Propofol decreases cerebral
blood flow and lowers intracranial pressure
www.medicinemcq.com 22
Parenteral vitamin K
Recommended empirically in all patients
www.medicinemcq.com 23
Cryoprecipitate In patients who have significant hypofibrinogenemia (100 mg/dL)
www.medicinemcq.com 24
Antifibrinolytic agents
Aminocaproic acid in hyperfibrinolytic state › Diffuse mucosal and puncture wound oozing
› Increased clot lysis time
www.medicinemcq.com 25
rFVIIa Recombinant factor VIIa
› when FFP has failed to correct PT/INR
› Volume overloaded Given before invasive
procedures with a high risk of bleeding
www.medicinemcq.com 26
H2 receptor antagonists/PPI
Incidence of upper GI bleeding decreased
www.medicinemcq.com 27
Blood glucose
Checked every 1–2 hrs High risk for hypoglycemia Hyperglycemia exacerbate
intracranial hypertension Insulin infusions - glucose
levels < 50 mg/dL
www.medicinemcq.com 28
Maintain CPP of 50–80 mm Hg
CPP = Mean arterial pressure – ICP Correct hypovolemia before
vasopressors › Norepinephrine preferred to
dopamine› Hydrocortisone improve the
vasopressor response to norepinephrine
www.medicinemcq.com 29
Fever
Exacerbates ICP Treat aggressively with cooling
blankets, fans, or other noninvasive devices
NSAIDs and acetaminophen are not recommended
www.medicinemcq.com 30
Renal function Urine sodium
› low (10 mEq/L) in prerenal azotemia and functional renal failure (hepatorenal syndrome)
› high in acute tubular necrosis Casts and renal tubular cells in the
urine suggest ATN IV fluid challenge (1L) to exclude
prerenal azotemia
www.medicinemcq.com 31
Serum electrolytes
Monitor once or twice daily
Hyponatremia ›Exacerbate edema›Avoided strictly
32
Mechanical Ventilation
May be needed
www.medicinemcq.com
www.medicinemcq.com 33
Etiology-specific therapy
Paracetamol poisoning - NAC Amanita - Penicillin G and NAC HSV – Acyclovir AIH - Methylprednisolone HBV - Lamivudine AFLP/HELLP - Delivery of fetus
www.medicinemcq.com 34
Amanita mushroom poisoning
Reduce the toxin load› Gastric lavage› Instillation of charcoal
Hemodialysis - remove toxins from the serum
Lower entero-hepatic toxin load - Uncertain › pencillin, cytochrome c, and silymarin
www.medicinemcq.com 35
Liver transplantation
Life-saving