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VAQ 3 Acute hepatic failure

VAQ 3 Acute hepatic failure. J TAYLOR. VAQ 7 2013.2. A previously well 38 yo man presents with a week of worsening vomiting, diarrhoea and abdominal pain. On the day of presentation to the ED he has become drowsy and confused.

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VAQ 3 Acute hepatic failure

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  1. VAQ 3Acute hepatic failure J TAYLOR

  2. VAQ 7 2013.2 • A previously well 38 yo man presents with a week of worsening vomiting, diarrhoea and abdominal pain. On the day of presentation to the ED he has become drowsy and confused. • Observations:Temp 37 oC Pulse 110/min BP 120/80mmHg GCS 12 (E3, V4, M5) • His liver function tests (LFTs) and coagulation profile are shown • Describe and interpret his results

  3. Focus on what it really asked! • A previously well 38 yo man presents with a week of worsening vomiting, diarrhoea and abdominal pain. On the day of presentation to the ED he has become drowsyand confused. • Observations:Temp 37 oC Pulse 110/min BP 120/80mmHg GCS 12 (E3, V4, M5) • His liver function tests (LFTs) and coagulation profile are shown • Describe and interpret his results (…and give brief DDx)

  4. LFTs • Bili 199 (<37) • ALP 152 (<105) • GGT 97 (<31) • ALT 7355 (<31) • AST 4583 (<31) • Alb 28 (>38) • Prot 65 (65-85) • Gluc 2 (3.0-6.0) • INR 2.1 (<1.3) • APTT 38 (27-43)

  5. Bili 199 (<37) high, clinically jaundiced • ALP 152 (<105) • GGT 97 (<31) mild elev– not primary obstruction • ALT 7355 (<31) • AST 4583 (<31) marked elevation – hepatitic pattern • Alb 28 (>38) low – reduced liver synthesis • Prot 65 (65-85) low/normal • Gluc 2 (3.0-6.0) low – reduced synthesis/GNG/malnourished • INR 2.1 (<1.3) raised/coagulopathy – reduced liver synthesis • APTT 38 (27-43) normal

  6. Good pass – covers the major issues • Acute hepatic failure with likely encephalopathy • DDx – viral hepatitis (A,B,C etc) • or toxins – paracetamol/mushroom poisoning • Not primarily obstructive • DDx Confusion due to hypoglycaemia/ICH • Reduced synthesis causing high INR/low albumin

  7. PASS criteria • “Acute Hepatic Failure with likely encephalopathy” • Recognise impaired synthetic function of liver. • differential for confusion i.e.: low BSL, ICH. • One viral hepatitis cause listed. One drug or toxin cause listed • Hepatitic liver failure rather than obstructive.

  8. Features of unsuccessful answers • Calling picture an obstructive pattern. • Did not recognise hepatic encephalopathy or consider other causes for altered GCS • Interpretation was not related to information given in stem. • eg – “on anticoagulants” • Rheumatoid arthritis/ulcerative colitis

  9. Lessons • Think before you leap • Interpret using all information given • Answer the stem • Keep your adjectives realistic • Include a brief differential relevant to the stem.

  10. Thank you

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