FULMINANT HEPATIC FAILURE - vims.ac.inFULMINANT HEPATIC FAILURE Definition “A clinical syndrome...
Transcript of FULMINANT HEPATIC FAILURE - vims.ac.inFULMINANT HEPATIC FAILURE Definition “A clinical syndrome...
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FULMINANT HEPATIC FAILURE
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FULMINANT HEPATIC FAILURE
Definition “A clinical syndrome characterized by encephalopathy and coagulopathy due to massive hepatocellular necrosis or sudden severe impairment of hepatocellular function , in a patient without any pre‐existing liver disease. It develops within 8 weeks of the onset of first symptoms attributable to the liver disease”
Trey‐Davidson(1970)
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FHF IN CHILDREN
• Trey Davidson’s definition not always applicable in children.
• E.g.: Chronic liver diseases like Wilson disease, galactosemia, NH etc. may present acutely as FHF
Early stages of hepatic encephalopathy difficult to assess in infants and neonates
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PAEDIATRIC ACUTE LIVER FAILURE STUDY GROUP (PALFSG) CRITERIA
• Biochemical evidence of liver injury
• No history of known liver disease
• Coagulopathy not corrected by vitamin K
administration.
• INR >1.5 if the patient has encephalopathy or > 2 if
the patient does not have encephalopathy.
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O’GRADY’S CLASSIFICATION OF FHF
Based on the time interval between jaundice and encephalopathy
• Hyperacute ‐ with in 1 week• Acute ‐ between 8‐28 days• Subacute ‐ between 29 days‐ 12 weeks
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FHF: AETIOLOGY ‐ THE ABCS
• A Acetaminophen, hepatitis A, autoimmune hepatitis
• B Hepatitis B; bacterial diseases‐ Weil’s disease;
septicemia; liver abscess
• C Cryptogenic ,hepatitis C, cardiac causes‐ CCF, CCHD, shock & myocarditis
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AETIOLOGY – CONT..
• D Hepatitis D, drugs (acetaminophen, aspirin, NH, NSAIDs, valproate, halothane)
• E Esoteric causes ‐ Wilson's disease, Budd‐Chiari syndrome
• F Fatty Infiltration – Reye’s syndrome• G Genetic diseases‐ galactosemia; HFI; Wilson
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AETIOLOGY –CONT…
• H – other Hepatitis viruses‐ HE, HG, TTV, Herpes simplex
• I ‐ Infiltration – leukemia, neuroblastoma, hepatoblastoma
• I ‐ Ischemic hepatitis‐ shock due to any cause
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FHF –AETIOLOGY (CONT..)
• Toxins
• Aflatoxin
• Amanita phalloides
• Carbon tetrachloride
• Indigenous medicines
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HISTORY IN FHF
• Consanguinity• Sibling death due to liver disease• Contact with VH• Risk factors for HB• Drugs• Toxins• Travel history
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INFECTIVITY OF HB
1 ml blood contains‐
1 trillion viral particles
Infective dose:
Just 0.00001 ml of blood!
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RISK FACTORS OF VBH
• Blood & blood products
• Needle stick injury
• Resheathing of needles
• IV drug abuse
• Mouth pipetting
• Shared tooth brush/razors
• Ear/ nose piercing
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PHYSICAL EXAMINATION
• Evidence of CLD• Cataract: galactosemia, HFI,WD• KF ring• Liver span• Ascites• Grade of coma• Complete CNS examination
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DAWSON’S SIGN(PALMAR ERYTHEMA)
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MONITORING LIVER SPAN
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GALACTOSEMIA
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WILSON DISEASE
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WHEN TO SUSPECT FHF IN A CHILD WITH VIRAL HEPATITIS
• Persistent anorexia
• Persistent vomiting
• Deepening jaundice
• Decreasing liver span
• Relapse of initial symptoms
• Development of ascites
• Neuropsychiatric changes19
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WHEN TO SUSPECT FHF: LAB CRITERIA
• S. bilirubin > 20 mg/dL
• Prolonged PT not corrected with vitamin K
• Very high ALT ( > 3000 IU/L), beyond 2 weeks
• Sudden fall in ALT without clinical improvement
• Leukocytosis
• Thrombocytopenia
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WHEN TO SUSPECT FHF (CONT..)
• Hypoglycemia
• Low BUN
• High ammonia
• Low albumin & fibrinogen
• Very low factor V levels
• Respiratory alkalosis
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ENCEPHALOPATHY
• Essential component for diagnosis
• Effect of HC failure on function of brain
• Accumulation of neurotoxins: ammonia,
glutamine, short chain fatty acids, mercaptans,
octopamine, GABA.
• Absence of neuroregulatory substances
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FHF –AETIOLOGY (CONT..)
• Toxins
• Aflatoxin
• Amanita phalloides
• Carbon tetrachloride
• Indigenous medicines
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FACTORS PRECIPITATING HE
• Constipation
• GI bleed
• Excess protein intake
• Hypokalemia, hyponatremia
• Hypoglycemia ,hypoxia
• Uremia
• Sepsis
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FACTORS PRECIPITATING HE (CONT..)
• Sedatives
• Tranquilizers
• Diuretics
• Paracentesis
• Surgical procedures
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COAGULOPATHY
• All clotting factors low except VWF& VIII
• Malabsorption of vitamin K
• Dysfibrinogenemia
• Thrombocytopenia
• Disseminated intravascular coagulation
• Prolonged PT,PTT
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ACID‐BASE IMBALANCE
• Resp alkalosis ‐ hyperventilation in early HE
• Metabolic alkalosis ‐ furesemide; hypokalemia
• Respiratory acidosis:
Respiratory failure
Cerebral edema
Obstructed ET tube
Pneumonia27
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ACID‐BASE IMBALANCE
Metabolic acidosis
• Metabolic failure‐ accumulation of org. acids
• Hypotension, poor perfusion‐ lactic acidosis
• Renal failure
• Mechanical ventilation
• Citrated blood
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BASE LINE ESSENTIAL INVESTIGATIONS
• CBC, Platelet count
• Blood group, Cross match
• PT,PTT, Factors V &VII
• LFT,RFT
• Electrolytes, Glucose
• Sepsis screen
• CXR , USS, EEG29
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DIAGNOSTIC INVESTIGATIONS
• Urine sugar‐ galactosemia, hereditary fructose intolerance
• Serum paracetamol levels• Wilson disease work up• Metabolic work up• Auto antibodies‐ LKM, ANA,SMA• High urine/serum succinyl acetone – type I tyrosinemia
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VIRAL MARKERS
• IgM anti HAV
• HBsAg
• IgM anticore Ab
• Anti‐delta, anti‐HCV
• PCR for HCV RNA
• Ig M anti HEV
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GENERAL MEASURES
• Blood, all secretions/excretions potentially infective
• Protective gowns, mask
• IV, radial artery& central venous catheters
• Nasogastric tube, saline lavage
• Bladder catheterization
• Fluid chart, vital signs, daily weight
• Cardio‐respiratory monitor
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HEPATIC ENCEPHALOPATHY
• Protein restriction ‐ 0.5g/kg/day
• Ampicillin / neomycin / rifaximin / metronidazole
• Lactulose / lactilol
• Bowel wash
• Prevention of GI bleed
• Flumazenil
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LACTULOSE
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MANAGEMENT OF HYPOGLYCEMIA
• Frequent monitoring( every 2‐ 4 hrs)
• IV glucose 25%‐ 2ml/kg
• Maintain glucose 40‐60 mg%
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COAGULOPATHY
• Mild ( PT <18 seconds)
• Moderate (PT 18‐25)
• Severe (PT >25)
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FHF –AETIOLOGY (CONTD)
• Toxins
• Aflatoxin
• Amanita phalloides
• Carbon tetrachloride
• Indigenous medicines
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COAGULOPATHY
• Vitamin K: 0.2‐0.3 mg/kg ‐ max 10 mg
• Mild coagulopathy ‐ no treatment
• Moderate: FFP(10 ml/kg 6 hourly) to reduce PT to 16‐
18 seconds
• Severe: FFP(15‐20 ml/kg 6 hourly) to reduce PT to 18‐25
• Cryoprecipitate, platelet transfusion
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PREVENTION OF GI BLEED
• Ranitidine 1‐2 mg/kg/dose IV 2‐4 times/day
• Omeprazole 0.5mg/kg/dose NG 1‐2 times/day
• Sucralfate 10‐20 mg/kg/dose NG 4‐6 hourly
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RENAL DYSFUNCTION IN FHF
• Pre‐renal failure
• Acute tubular necrosis
• Hepatorenal syndrome ‐ commonest
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HYPOKALEMIA
• Injudicious diuretics
• Secondary hyperaldosteronism
• Excessive vomiting
• Nasogastric aspiration
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HYPONATREMIA
• Decreased water excretion by kidneys
• Increased ADH
• Excess use of hypotonic fluids
• Frusemide
• Restrict fluids to 75% of maintenance
• Do not correct with saline
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INFECTION IN FHF
90% have clinical e/o bacterial infectionFactors predisposing to infections‐• Poor host defense• Impaired Kupffer and polymorph function• Low opsonins, fibronectin, complement• Poor cough reflex• ET tubes, catheters, venous lines
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INFECTIONS IN FHF (CONTD)
• Pneumonia‐ commonest
• Urinary tract infection
• Septicemia
• Gram positive in 60%‐staph/strep
• Gram negative bacilli
• Fungal infections in 30%
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CEREBRAL EDEMA
• One of the most common cause of death
• ICP is above 30 mmHg
• Clinical detection difficult
• Sudden change in level of consciousness
• Anisocoria, hypertonia, seizures
• Decerebrate posturing, papilledema
• Bradycardia with rising BP
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CEREBRAL EDEMA(CONT..)
• Seen in 80% of fatal cases• Grade III‐IV encephalopathy• Raise head end 450
• Fluid restriction, IV mannitol• Avoid hyperthermia • Ventilate if HE> grade III Extradural monitors ‐ Ladd transducers Subdural monitors ‐ Gaeltec monitors
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BRAIN EDEMA FHF
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SPECIFIC THERAPY IN FHF
• N‐acetylcysteine in paracetamol poisoning
• Benzyl penicillin & thioctic acid in Amanita
poisoning
• Acyclovir in herpes simplex
• D‐penicillamine ‐ Wilson disease
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SPECIFIC THERAPY IN FHF
• Artificial liver support
• Hepatocyte transplantation
• Liver transplantation
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ARTIFICIAL LIVER SUPPORT SYSTEM
• Molecular Absorbent Recirculating System (MARS)
• Albumin impregnated dialysis membrane and a dialysate
containing 5% human albumin
• Removes water soluble toxins including NH3
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BIO‐ARTIFICIAL LIVER SUPPORT
• Bio‐reactors containing viable hepatocytes in culture
• Bio‐artificial Liver (BAL)
• Extra‐corporial Liver Assist Device ( ELAD)
• Berlin Extracorporeal Liver Assist Device (BELS)
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KING’S COLLEGE CRITERIA FOR LIVER TRANSPLANTATION
• Paracetamol induced FH
• pH < 7.3 (irrespective of grade of HE)
OR
• PT >100 sec
• Creatinine >300 micromol/L or >3.4 mg%
• Grade 3 or 4 HE
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KING’S COLLEGE CRITERIA (CONT..)
Non‐paracetamol patientsPT >100 sec(INR>7) (irrespective of HE grade) Or any 3 of these, irrespective of HE grade :•Age <10 or 40 years•PT >50 seconds (INR > 3.5)•SB >17.5 mg%•Non‐ A‐E hepatitis; halothane hepatitis ; idiosyncratic drug reactions•Duration of jaundice before onset of HE>7 days
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GOOD PROGNOSTIC FACTORS
• Age : 10 ‐ 40 years
• Hepatitis A
• Paracetamol poisoning if treated in time
• Presence of an obvious etiology
• Stage I/II HE
• Increased alpha‐fetoproteins‐ as it is a sign of
hepatocellular regeneration
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SURVIVAL RATE IN FH
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ETIOLOGY OF FH SURVIVAL (%)
Hepatitis AParacetamol poisoningHepatitis BNA-G hepatitisHalothane
7050402010
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CAUSES OF DEATH
• Cerebral edema
• Septicemia/fungemia
• Respiratory failure
• Hemorrhagic diathesis
• Complications of LT
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Prevention of FHF
• Hepatitis B & A vaccination
• Monitoring of patients on ATT/NSAIDs
• Avoid paracetamol over dose
• Avoid aspirin‐ Reye syndrome
• Avoid Afla toxins, amanita
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Thank You
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