Acute Liver Failure

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Acute Liver Failure
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• 30 year old woman presents to hospital with a two
  day history of nausea, vomiting, and right upper
  quadrant pain.
• She has been healthy and denies any medication
  use.
• She recently traveled to Vietnam where she
  twisted her ankle while bungee jumping. The pain
  has been well controlled with over the counter
  and natural remedies.

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• On examination, she is slightly confused to date
  and in moderate distress from the pain.
• Vital signs are 123/41, heart rate 109,
  respiratory rate 24, and saturations 95 on room
  air.
• She is has diffuse abdominal tenderness and
  palpable liver edge with a scleral icterus.

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• What is the most likely cause of this patients
  presentation?
• What are the common etiologies of acute liver
  failure?
• Consider
• A acetaminophen, hepatitis A, autoimmune
• B hepatitis B
• C cryptogenic, hepatitis C
• D hepatitis D
• E esoteric causes such as Wilsons and
  Budd-Chiari
• F fatty infiltration such as fatty liver of
  pregnancy and Reye

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• Initial bloodwork comes back
• ALT 3826, AST 4826, TBili 59, Alk Phos 283,INR
  4.2, creatinine 436, pH 7.31
• What in the history gives us clues to the cause?
• Travel hepatitis virus?
• Over the counter drugs acetaminophen?
• Natural remedies drug or toxin?
• Childbearing age fatty liver of pregnancy?

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• Obtaining further history, her family tells you
  that she has been vaccinated against hepatitis B
  because she is a lab tech, she is not pregnant
  but do not know what medications and remedies she
  takes.
• You take the history from the family because the
  patient is rapidly becoming unresponsive.

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• What is the definition of fulminant hepatic
  failure?
• Severe acute liver injury with impaired synthetic
  function and encephalopathy in a person with a
  normal liver or well-compensated liver disease.
• What are the grades of encephalopathy?
• The patient has become completely unresponsive
  with posturing to stimulation. You rapidly
  intubate and resuscitate her and obtain an urgent
  CT scan.

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Head CT
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• What has happened?
• How do you grade hepatic encephalopathy?

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• How do you treat hepatic encephalopathy with and
  without intracranial hypertension?
• What is the role for intracranial monitoring in
  this case?

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• After appropriate resuscitation and treatment,
  the patient is more stable. The family
  approaches you for more information. They want
  to know whether she is going to need liver
  transplant.
• What do you tell them and how do you know?

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By the way, what are some of the drugs that can
cause fulminant hepatic failure?

• Acetaminophen
• Alcohol
• Amiodarone
• Carbon tetrachloride
• Dideoxyinosine
• Gold
• Halothane
• Isoniazid
• Ketoconazole
• MAO inhibitors
• Methyldopa
• NSAIDs
• Phenytoin
• Poison mushrooms (Amanita phalloides)
• Propylthiouracil
• Rifampin
• Sulfonamides
• Tetracycline
• Tricyclic antidepressants

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Next patient

• 68 year old man with known chronic liver
  dysfunction from NASH.
• He presents to his family doctor with increasing
  confusion. He admits the patient to hospital and
  consults you because of persisting fevers.
• On assessment, he is febrile, slightly jaundiced
  with signs of chronic liver disease and abdominal
  tenderness.
• Blood cultures come back positive for E. coli

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• What is the most likely problem?
• How is the diagnosis of spontaneous bacterial
  peritonitis made?
• A paracentesis reveals a WBC count of 375
  cells/mL with 95 PMNs.
• What is the appropriate treatment of spontaneous
  bacterial peritonitis?

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• The next day, the patient feels better but his
  urine output has been poor.
• His creatinine is 242, last level 6 months ago
  was 109.
• What are the possible causes of this problem?
• Consider
• Volume depletion from paracentesis
• Abdominal compartment syndrome
• ATN from nephrotoxins such as aminoglycosides
• Interstitial nephritis from B-lactams
• Hepatorenal syndrome
• How would you investigate this?

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• There is no change in renal function after fluid
  challenges and his urine sodium is lt 10 mmol/L.
• What is the criteria for hepatorenal syndrome?
• What is the pathophysiology behind hepatorenal
  syndrome?

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• The diagnosis of HRS is confirmed. The family
  asks you what this means. He has refused
  transplant workup and long term dialysis.
• What do you tell the family?
• What is the role of albumin in HRS?
• What is the role of vasopressors such as
  midodrine/octreotide or levophed/vasopressin in
  HRS?

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Questions??