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Acute Liver F ailure Tutorial

Learn about acute liver failure, its common causes, symptoms, medical management, and when to consider transplantation. Includes case studies and diagnostic approaches. Understand lab investigations, complications, and prevention strategies.

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Acute Liver F ailure Tutorial

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  1. Acute Liver FailureTutorial Ayman Abdo

  2. Objectives After the discussion in this educational exercise, I want you to be able to : • Identify common causes of acute liver failure through history and examination • Recognize common presentations • Be familiar with medical management • Know when to refer a patient for transplantation

  3. Acute Liver FailureDefinition • Rapid hepatocellular dysfunction • Encephalopathy • No pre-existing liver disease

  4. Common causes of acute liver failure • Viral hepatitis: Hep A, Hep B • Toxin/drug • Ischemic • Autoimmune hepatitis • Wilson disease

  5. Pt 1: Initial history • 66 y old female • Chronic abdominal pain and constipation • Otherwise healthy • 3 day history of jaundice and confusion

  6. Patient 1 What other questions are you going to ask?

  7. 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

  8. 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

  9. Patient 1 What physical signs are you going to look for?

  10. Physical examination • Vital signs • Level of conciseness • Flapping tremor • Stigmata of chronic liver disease • Ophthalmology exam if indicated • Full abdominal examination • Full neurological examination

  11. Patient 1 What labs are you going to order?

  12. Important labs • CBC and electrolytes • Liver enzymes : ALT, AST, ALP, GGT, LDH • Liver function tests: INR, Albumine, Bili • Viral hep serology= HAV IgM, Hep B cAb IgM, HCV RNA • Toxic screen: Acetaminophen level • AIH markers: ANA, ASMA • Wilson: Ceruloplasmin, urine cupper • Others

  13. Causes of acute liver failure • Viral hepatitis: Hep A, Hep B • Toxin/drug • Ischemic • Autoimmune hepatitis • Wilson disease

  14. Lab investigations • CBC • Electrolytes • 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

  15. Pattern in Ischemic hepatitis

  16. Ischemic vs. viral

  17. Get more information ?

  18. Complications&Management

  19. Specific therapy • Viral: • Ischemic: • Toxic: Acetaminophen (N-acetyl cystein) • Autoimmune • Wilson

  20. Which pt will recover with intensive medical therapy and which pt requires transplantation?

  21. 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 <10 or >40 yrs Bili > 300 Coagulopathy: INR > 3.5 Duration of jaundice > 7 days before HE Etiology: Non A-E, other drug King’s College Criteria O’Grady et al. Gastroenterology 1989;97:439

  22. MARS : Molecular adsorbents recycling system

  23. What is the best way to prevent acute fulminant liver failure?

  24. درهم وقاية خير من قنطار علاج

  25. What is the best way to reduce the incidence of acute fulminant liver failure?

  26. Prevention • HBV Vaccination • HAB vaccination • Avoid herbs • Careful with drugs • Clean food • Sexual practices • Volume ressiciatation

  27. More quick cases

  28. Case 2 • A 33 y old female • Just came back from Umrah • Has 2 day history of dark urine and yellow eyes • No new medications

  29. Patient 2 What are the possible causes of this presentation?

  30. Case 2 • No physical signs except for jaundice • No encephalopathy • ALT=2300, AST=1700, ALP=480, GGT=789, INR=2.1

  31. Patient 2 How would you manage this patient?

  32. Patient 3 • 55 y old male • Massive acute MI • Successful resuscitation • Cardiac condition stable • 5 days later: ALT=2300, AST=2000, LDH=4500

  33. Patient 3 What is the most likely cause?

  34. Patient 3 How would you manage this patient?

  35. Patient 4 • 22 y old male • Previously healthy • 1 week history of jaundice • ALT=1500, AST=3400, ALP=450, INR=1.8 • CBC= HB=7.8, WBC=10.8, PLt=340

  36. Patient 4 What is the most likely cause?

  37. Patient 4 • Cerulopasmin= very low • 24 urinary cupper= very high • Ophthalmology exam= KFR

  38. 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

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