View source for Acute hepatic failure

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==Background== <!--T:1-->

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[[File:Liver vascular anatomy.png|thumb|Liver vascular anatomy.]]

===Definitions=== <!--T:3-->

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*Hyperacute liver failure: encephalopathy occurs within 7 days of the onset of jaundice; this subset is likely to survive with medical management despite the high incidence of cerebral edema<ref>O’Grady, JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. July 1993, Volume 342, Issue 8866, Page 273-275</ref>
*Acute liver failure: interval of 8-28 days from jaundice to encephalopathy; this subset has a high incidence of cerebral edema and a poorer prognosis without liver transplant<ref>O’Grady, JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. July 1993, Volume 342, Issue 8866, Page 273-275</ref>
*Subacute liver failure: interval of 5-12 weeks from the onset of jaundice to the onset of encephalopathy; this subset has a lower incidence of cerebral edema, but a poor prognosis<ref>O’Grady, JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. July 1993, Volume 342, Issue 8866, Page 273-275</ref>

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{{Acute hepatitis causes}}
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{{Drug or Toxin Related Liver Disease}}
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===Other Rare Causes of Acute Liver Failure=== <!--T:5-->

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*'''[[Special:MyLanguage/Wilson's disease|Wilson's disease]]''': unexplained elevations in LFTs, neuro-psychiatric symptoms, Kayser-Fleischer rings on eye exam
*'''[[Special:MyLanguage/Autoimmune hepatitis|Autoimmune hepatitis]]''': more common in women, liver disease without explanation, may have family history of other autoimmune disorders
*'''[[Special:MyLanguage/Hemochromatosis|Hemochromatosis]]''': family history of liver disease and cardiac disease
*'''[[Special:MyLanguage/Budd-Chiari|Budd-Chiari]]''': history of hypercoagulable disorder, abdominal pain, and ascites


==Clinical Features== <!--T:7-->

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[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
[[File:Hepaticfailure.jpg|thumb||Ascites secondary to [[Special:MyLanguage/cirrhosis|cirrhosis]].]]
[[File:Jaundice.jpg|thumb|Pediatric jaundice with icterus of sclera.]]
*Common findings in acute liver failure
**Tender [[Special:MyLanguage/hepatomegaly|hepatomegaly]]
**[[Special:MyLanguage/Jaundice|Jaundice]]
**[[Special:MyLanguage/Hepatic encephalopathy|Hepatic encephalopathy]]
**Asterixis
*Common findings in chronic liver failure
**[[Special:MyLanguage/Ascites|Ascites]]
**Caput medusae
**Palmar erythema
**Spider angiomata
**Gynecomastia
**Testicular atrophy
**Parotid gland enlargement
**Muscular atrophy
**May also have [[Special:MyLanguage/jaundice|jaundice]], [[Special:MyLanguage/hepatic encephalopathy|encephalopathy]], and asterixis as in acute liver failure


==Differential Diagnosis== <!--T:9-->


===[[Special:MyLanguage/Encephalopathy|Encephalopathy]] (altered mental status)=== <!--T:10-->

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*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*[[Special:MyLanguage/Hypoxia|Hypoxia]]
*[[Special:MyLanguage/Intracerebral hemorrhage|Intracerebral hemorrhage]] or mass
*[[Special:MyLanguage/Meningitis|Meningitis]]/[[Special:MyLanguage/encephalitis|encephalitis]]
*[[Special:MyLanguage/CVA|CVA]]
*[[Special:MyLanguage/Alcohol intoxication|Alcohol intoxication]]
*[[Special:MyLanguage/Myxedema coma|Myxedema coma]]
*[[Special:MyLanguage/Wernicke encephalopathy|Wernicke encephalopathy]]
*[[Special:MyLanguage/Sepsis|Sepsis]]
*[[Special:MyLanguage/Seizure|Seizure]]/post-ictal state
*[[Special:MyLanguage/Uremia|Uremia]]
*[[Special:MyLanguage/Electrolyte abnormality|Electrolyte abnormality]]
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]


===[[Special:MyLanguage/Jaundice|Jaundice]]=== <!--T:12-->

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*[[Special:MyLanguage/Hepatic dysfunction|Hepatic dysfunction]]
*[[Special:MyLanguage/Biliary disease|Biliary disease]] (e.g. [[Special:MyLanguage/Choledocholithiasis|CBD obstruction]])
*[[Special:MyLanguage/hemolytic anemia|Hemolysis]]
*[[Special:MyLanguage/Pregnancy|Pregnancy]]
*Congenital diseases (e.g. [[Special:MyLanguage/inborn errors of metabolism|inborn errors of metabolism]]; (more likely to present in early childhood)

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{{Hepatomegaly DDX}}
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==Evaluation== <!--T:14-->


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*[[Special:MyLanguage/LFTs|LFTs]]
**AST and ALT
***Enzymes found mainly in hepatic cells, though ALT is more specific to the liver than AST
***Extreme elevation in AST (>3000U/L, or >40x upper limit of normal) is consistent with acetaminophen toxicity or ischemic injury
***Moderate elevations (10-40x upper limit of normal) is consistent with viral hepatitis
***Mild elevations (<10x upper limit of normal) is consistent with alcoholic hepatitis
**Alkaline Phosphatase
***Found in bile canaliculi (but also in placenta, ileal mucosa, bone, and kidney)
***Elevated in diseases of cholestasis
***Rare for levels to be >3x normal limit in acute liver failure
**Bilirubin
***Elevated in diseases of cholestasis
***In obstructive diseases, the direct bilirubin will usually be about 50% of the total bilirubin; if indirect bilirubin is higher, more suggestive of hemolysis or problem with conjugation
*Coagulation Studies
**Reflects the liver’s ability to synthesize clotting factors
**INR >6.5 or PT >20 seconds indicates patients at high risk for death
*Albumin
**Reflects synthetic function of the liver
**Has a long half-life (20 days) and may not be decreased early in disease
*Ammonia
**Elevated as a result of impaired clearance
**Poor correlation between degree of elevation and severity of encephalopathy symptoms
*Chemistry Panel
**Electrolyte abnormalities may indicate malnutrition or dehydration
**Creatinine is used as a prognostic indicator
**Need to check a glucose because patients with liver failure are prone to hypoglycemia
*CBC
**Not useful in diagnosing the cause of liver failure, but helpful in determining coexisting [[Special:MyLanguage/infection|infection]], [[Special:MyLanguage/anemia|anemia]], [[Special:MyLanguage/thrombocytopenia|thrombocytopenia]]
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]] Serologies
**Consider for all patients with undifferentiated liver failure
**IgM anti-HBc may be the only positive marker in acute Hepatitis B infection
**Anti-HCV and HCV RNA are present in both chronic and acute Hepatitis C infections, so it is difficult to differentiate based on serologies, but presence of HCV RNA in the absence of anti-HCV is more suggestive of acute infection<ref>Bailey, C, Hern HG. Hepatic Failure: An Evidence-Based Approach In The Emergency Department. Emergency Medicine Practice. Vol. 12, No. 4, 2014.</ref>
**Only need to test for IgM anti-HEV in patients who are symptomatic and have just travelled from areas where Hepatitis E is endemic


===Imaging=== <!--T:17-->

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*Consider [[Special:MyLanguage/RUQ US|RUQ US]] or CT in patients with jaundice to evaluate for a mechanical obstruction
*Otherwise, tailor imaging towards specific complaints

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{{Ascites Evaluation}}
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==Management== <!--T:19-->

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*Treatment is mostly supportive and tailored towards the specific etiology
*Early consideration regarding transporting patient to a transplant center given potential for rapid deterioration
*Symptom specific supportive treatment options
**[[Special:MyLanguage/Hepatic encephalopathy|Encephalopathy]]: consider [[Special:MyLanguage/lactulose|lactulose]] of [[Special:MyLanguage/neomycin|neomycin]]
**[[Special:MyLanguage/Seizures|Seizures]]: consider [[Special:MyLanguage/phenytoin|phenytoin]] over [[Special:MyLanguage/benzodiazepines|benzodiazepines]] (prevent benzodiazepine oversedation secondary to decreased hepatic clearance)
**[[Special:MyLanguage/Increased ICP|Intracranial Hypertension]]: elevated head of bed, [[Special:MyLanguage/mannitol|mannitol]], short-term hyperventilation; hypothermia may be a bridge to transplant; no benefit from steroids
**[[Special:MyLanguage/liver disease induced coagulopathy|Coagulopathy]]
***Prophylactic normalization of the INR is not necessary unless procedure (such as paracentesis) is planned; then can give [[Special:MyLanguage/Vitamin K|Vitamin K]]
***Recommend [[Special:MyLanguage/platelet transfusion|platelet transfusion]] to 10K for asymptomatic patients, and to 50-70K for patients undergoing invasive procedures	
**See [[Special:MyLanguage/Acetaminophen toxicity|Acetaminophen toxicity]] for specifics regarding treatment of acetaminophen toxicity
**See [[Special:MyLanguage/Spontaneous Bacterial Peritonitis|Spontaneous Bacterial Peritonitis]] for specifics regarding diagnosis and treatment of SBP


==Disposition== <!--T:21-->

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*Admission to ICU with early consideration for transportation to transplant center


==See Also== <!--T:23-->

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*[[Special:MyLanguage/Jaundice|Jaundice]]
*[[Special:MyLanguage/Cirrhosis|Cirrhosis]]
*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
*[[Special:MyLanguage/Hepatic encephalopathy|Hepatic encephalopathy]]


==References== <!--T:25-->

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<references/>

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[[Category:GI]]
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