Flashcards in 10 - Hepatic Encephalopathy and Acute Liver Failure Deck (59)
If the liver recovers
It regenerates completely
If the liver fails acutely
Patient dies within 4 - 7 days
What do you see in halothane-induced hepatic failure?
Little bile ducts re-forming!
Sadly, most patients don't make it long enough for the regeneration!!!!
Acute Liver Failure - Syndrome
Altered Mentation (Hepatic Encephalopathy)
Coagulopathy (INR >- 1.5)
Acute Illness (
Acute-on-Chronic Liver Disease
Never has cerebral edema
Refers to when someone with chronic liver disease has an acute failure.
Acute Liver Failure - Management
Establish Diagnosis (INR, AMS, new hepatic illness)
Determine Etiology (history, Labs)
Estimate Severity (Exam, Labs)
Acute Liver Failure - How do we treat different etiologies?
Acetaminophen? --> Tx = N-Acetyl Cysteine
Mushrooms (not the magic kind. The dad kind.) ? --> Tx = Penicillamine/silibinin antidote
Wilsons? (Elevated bilirubin, low AP, Increased Ucu)? --> Tx = OLTx
Drug-Induced/Viral/Indeterminate? --> Tx = Good Intensive Care
Acute Liver Failure - How do we estimate severity?
ICU Monitoring / Management
Transplant evaluation / Planning (start early!)
Fulminant Hepatic Failure - Etiologies
Viruses (HAV, HBV, HDV, HEV)
Other viruses you can't find (they are hepatotrophic)
Toxins (Amanita Mushrooms)
Metabolic Diseases (Wilson's)
Others (AFLP, Heat Stroke, Autoimmune)
Fulminant Hepatic Failure - Acetaminophen
Billion dollar product - OTC more than 300 brands
Unique dose-related toxin
100,000 calls to Poison Control annually
50,000 ER visits/year
Current assay measures only the acetaminophen parent compound, not the toxic metabolite
Acute Liver Failure - Other Drugs
8 INH without other anti-TB drugs
2 with other non-TB drugs
5 INH + rifampin + pyrazinamide
1 INH + Ethambutol
2 rifampin + pyrazinamide
Herbals and/or dietary supplements 9
(including 2 Kava-Kava
Fulminant Hepatic Failure - Therapy
Avoid FFP, sedatives until decision on transplant reached
Short trial of lactulose may help
Transfer to transplant center before complications develop
Fulminant Hepatic Failure - Infection
Happens in MOST patients!! (80% of patients)
Documented bacteremia in 20 - 25%
Secondary to gut translocation, decreased ReticuloEndothelial function and instrumentations
Gram negatives, Staph, Strep with fungal infection in up to 33%
Fulminant Hepatic Failure - Infection Plan
Culture all patients broadly with a low threshold for empiric antibiotics
Prophylactic antifungals if renal failure or on abx already.
Fulminant Hepatic Failure - Renal Failure
Occurs in up to 33% of patients
Often multifactorial - Volume depletion, ATN, hepatorenal
Urine sodium may be helpful (if it's low)
Avoid CT contrast, empiric aminoglycosides
Since patients tolerate volume overload poorly, CVP or PA monitoring is important!
If oliguria persists with normal CVP --> CVVH
It's not hepatorenal
If they don't have massive portal HTN (either ascites or acute - vessel thrombosed or acute liver failure)
How do we make Acute Liver Failure-induced Renal Failure worse?
CT Contrast (dangerous!)
Flood them with fluids! - Leads to cerebral edema!!
What is the only imaging you should order in the case of Acute Liver Failure?!
Ultrasound with doppler examination of the hepatic vessels
Unless you suspect that the reason is massive malignant infiltration of the liver
Indication for dialysis in acute liver failure
Not making urine
What happens if you fill an Acute Liver Failure patient who has developed Renal Failure with fluids?!
Complications in Acute Liver Failure that resolve on their own if the liver is transplanted
Complications in Acute Liver Failure that DON'T resolve on their own if the liver is transplanted!!!!
Contraindications to Transplant!!!
Can give ARDS, ATN, Peripheral Vasodilatation with Hypotension, and DIC
Difficult to separate from Sepsis
Can be a contraindaction to OLT (particularly ARDS)
Treatment is supportive only.
Acute Liver Failure - Contraindications to Transplant!!
Fulminant Hepatic Failure - Cerebral Edema
Most common cause of death in patients with Acute Liver Failure
Present in up to 80% of patients DYING with FHF
The remaining 20% died of septic shock.
Difficult to diagnose with CT, early monitoring essential
If untreated, leads to herniation. Transplantation is the only "cure" but it takes 48 hours to reduce the edema!
Barbiturates, mannitol, hyperventilation & elevation of the head MAY halp!
Fulminant Hepatic Failure - Timing of Transplantation
80% of patients with fulminant hepatic failure who survive successful liver transplants have them in the first 48 hours
Early transfer to transplant center is key
Role of extracorporeal liver assist devices inconclusive
Median waiting time of a Status 1 on the transplant list in the USA
1 1/2 days
Pediatric Acute Liver Failure
Syndrome same as adults
Etiology is different:
52% are indeterminate (probably non-A-through-C viral hepatitis)
Acetaminophen Origins - Often through therapeutic mistakes. Infant tylenol is more concentrated than children's tylenol. Also suicidal teens.
Indications for OLT in Fulminant Hepatic Failure
King's College Criteria:
Acetaminophen-Induced (higher rate of spontaneous recovery)