Acute liver failure Tutorial
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Transcript of Acute liver failure Tutorial
Acute liver failureAcute liver failureTutorialTutorial
Ayman Abdo Ayman Abdo MD, FRCPCMD, FRCPC
ObjectivesObjectives
After the discussion in this educational After the discussion in this educational exercise, I want you to be able to :exercise, I want you to be able to :
Identify common causes of acute liver failure Identify common causes of acute liver failure through history and examinationthrough history and examination
Recognize common presentationsRecognize common presentations
Be familiar with medical managementBe familiar with medical management
Know when to refer a patient for Know when to refer a patient for transplantationtransplantation
Acute Liver FailureAcute Liver FailureDefinitionDefinition
1.1. Rapid hepatocellular Rapid hepatocellular dysfunctiondysfunction
2.2. Encephalopathy Encephalopathy
3.3. No pre-existing liver No pre-existing liver diseasedisease
Common causes of acute liver failureCommon causes of acute liver failure
Viral hepatitis: Hep A, Hep BViral hepatitis: Hep A, Hep B
Toxin/drugToxin/drug
IschemicIschemic
Autoimmune hepatitisAutoimmune hepatitis
Wilson disease Wilson disease
Pt 1: Initial historyPt 1: Initial history
66 y old female66 y old female
Chronic abdominal pain and constipationChronic abdominal pain and constipation
Otherwise healthyOtherwise healthy
3 day history of jaundice and confusion3 day history of jaundice and confusion
Patient 1Patient 1
What other questions What other questions are you going to ask?are you going to ask?
Important questions on historyImportant questions on history
Recent travelRecent travelSexual exposureSexual exposureIVDUIVDUContact with jaundiced ptContact with jaundiced ptDetailed drug history including herbsDetailed drug history including herbsAutoimmune featuresAutoimmune featuresNeurological symptomsNeurological symptomsRecent hypotension or sepsesRecent hypotension or sepses
Pt 1 : More historyPt 1 : More history
Dx to have IBSDx to have IBS
Started on herbal medication 1 week agoStarted on herbal medication 1 week ago
No viral hepatitis risk factorsNo viral hepatitis risk factors
No hypercoagulable disorderNo hypercoagulable disorder
No new medicationsNo new medications
Patient 1Patient 1
What physical signs are What physical signs are you going to look for?you going to look for?
Physical examinationPhysical examination
Vital signsVital signs
Level of concisenessLevel of conciseness
Flapping tremorFlapping tremor
Stigmata of chronic liver diseaseStigmata of chronic liver disease
Ophthalmology exam if indicatedOphthalmology exam if indicated
Full abdominal examinationFull abdominal examination
Full neurological examinationFull neurological examination
Patient 1Patient 1
What labs are you going What labs are you going to order?to order?
Important labsImportant labs
CBC and electrolytesCBC and electrolytesLiver enzymes : ALT, AST, ALP, GGT, LDHLiver enzymes : ALT, AST, ALP, GGT, LDHLiver function tests: INR, Albumine, BiliLiver function tests: INR, Albumine, BiliViral hep serology= HAV IgM, Hep B cAb IgM, Viral hep serology= HAV IgM, Hep B cAb IgM, HCV RNAHCV RNAToxic screen: Acetaminophen levelToxic screen: Acetaminophen levelAIH markers: ANA, ASMAAIH markers: ANA, ASMAWilson: Ceruloplasmin, urine cupperWilson: Ceruloplasmin, urine cupperOthersOthers
Causes of acute liver failureCauses of acute liver failure
Viral hepatitis: Hep A, Hep BViral hepatitis: Hep A, Hep B
Toxin/drugToxin/drug
IschemicIschemic
Autoimmune hepatitisAutoimmune hepatitis
Wilson disease Wilson disease
Lab investigationsLab investigations
CBCCBC
ElectrolytesElectrolytes
Liver enzymes (ALT, AST, ALP, GGT, LDH)Liver enzymes (ALT, AST, ALP, GGT, LDH)
Liver function tests (Bili, Albumin, INR)Liver function tests (Bili, Albumin, INR)
Hep A (IgM, IgG), Hep B (HBsAG, HBcIgM)Hep A (IgM, IgG), Hep B (HBsAG, HBcIgM)
Acetaminophen levelAcetaminophen level
ANAANA
Cerulopasmin, 24 h copper collectionCerulopasmin, 24 h copper collection
Pattern in Ischemic hepatitisPattern in Ischemic hepatitis
Ischemic vs. viralIschemic vs. viral
Get more information ?Get more information ?
ComplicationsComplications&&
ManagementManagement
Specific therapySpecific therapy
Viral:Viral:
Ischemic:Ischemic:
Toxic: Toxic:
Acetaminophen (N-acetyl cystein)Acetaminophen (N-acetyl cystein)
AutoimmuneAutoimmune
WilsonWilson
Which pt will recover with Which pt will recover with intensive medical therapy and intensive medical therapy and
which pt requires which pt requires transplantation?transplantation?
King’s College CriteriaKing’s College Criteria
AcetaminophenAcetaminophen
pH < 7.3pH < 7.3
oror
Grade III or IV HE Grade III or IV HE andand– INR > 6.5INR > 6.5– Creatinine > 300Creatinine > 300
Non-acetaminophenNon-acetaminophenINR > 6.5INR > 6.5or any 3/6or any 3/6– AAge <10 or >40 yrsge <10 or >40 yrs– BBili > 300ili > 300– CCoagulopathy: INR > 3.5oagulopathy: INR > 3.5– DDuration of jaundice uration of jaundice
> 7 days before HE> 7 days before HE– EEtiology: Non A-E, other drugtiology: Non A-E, other drug
O’Grady et al. Gastroenterology 1989;97:439
MARS : Molecular adsorbents recycling system
More quick casesMore quick cases
Case 2Case 2
A 33 y old femaleA 33 y old female
Just came back from UmrahJust came back from Umrah
Has 2 day history of dark urine and yellow Has 2 day history of dark urine and yellow eyeseyes
No new medicationsNo new medications
Patient 2Patient 2
What are the possible What are the possible causes of this causes of this presentation?presentation?
Case 2Case 2
No physical signs except for jaundiceNo physical signs except for jaundice
No encephalopathyNo encephalopathy
ALT=2300, AST=1700, ALP=480, ALT=2300, AST=1700, ALP=480, GGT=789, INR=2.1GGT=789, INR=2.1
Patient 2Patient 2
How would you manage How would you manage this patient?this patient?
Patient 3Patient 3
55 y old male 55 y old male
Massive acute MIMassive acute MI
Successful resuscitationSuccessful resuscitation
Cardiac condition stableCardiac condition stable
5 days later: ALT=2300, AST=2000, 5 days later: ALT=2300, AST=2000, LDH=4500LDH=4500
Patient 3Patient 3
What is the most likely What is the most likely cause?cause?
Patient 3Patient 3
How would you manage How would you manage this patient?this patient?
Patient 4Patient 4
22 y old male22 y old male
Previously healthyPreviously healthy
1 week history of jaundice 1 week history of jaundice
ALT=1500, AST=3400, ALP=450, INR=1.8ALT=1500, AST=3400, ALP=450, INR=1.8
CBC= HB=7.8, WBC=10.8, PLt=340CBC= HB=7.8, WBC=10.8, PLt=340
Patient 4Patient 4
What is the most likely What is the most likely cause?cause?
Patient 4Patient 4
Cerulopasmin= very lowCerulopasmin= very low
24 urinary cupper= very high24 urinary cupper= very high
Ophthalmology exam= KFROphthalmology exam= KFR
ConclusionConclusion
The most important three causes of acute liver The most important three causes of acute liver failure are : viral hepatitis, toxic hepatitis, and failure are : viral hepatitis, toxic hepatitis, and ischemic hepatitisischemic hepatitis
Less likely causes include: Autoimmune Less likely causes include: Autoimmune hepatitis, Wilson disease, malignant infiltrationhepatitis, Wilson disease, malignant infiltration
Early recognition and treatment of the causeEarly recognition and treatment of the cause
Medical management of complicationMedical management of complication
Decide early about transplantationDecide early about transplantation