Acute liver failure Flashcards
what is the definition of ALF?
Acute liver failure (ALF) is a rapid decline in hepatic function characterised by jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy in patients with no evidence of prior liver disease.
what is the epidemiology of ALF?
Rare
3% of liver transplants
Majority women aged 40 yrs
what is the aetiology of ALF?
UK and US = paracetamol overdose
Other causes - idiosyncratic drug-induced liver injury, acute hep B, autoimmune hepatitis, ischaemic hepatitis, acute hep A
what are the risk factors for ALF?
Chronic alcohol abuse Poor nutrition Female Over 40 Pregnancy Hep B Pain Narcotic use Complementary and alternative medicine hepatotoxicity
what is the pathophysiology of ALF?
Most cases are characterised by massive hepatocyte necrosis, which may ultimately result in organ failure. On a cellular level, both hepatocyte necrosis and apoptosis may coexist in the setting of ALF. ALF can occur without histological evidence of hepatocellular necrosis; examples of this include acute fatty liver of pregnancy and Reye’s syndrome. Efforts to more accurately define factors involved in the pathogenesis of liver injury in the setting of ALF, including hepatocyte apoptosis and regeneration, may lead to the discovery of novel biomarkers that could predict outcomes.
what are the key presentations of ALF?
Presence of risk factors
Hepatotoxic medication
Jaundice
Signs of hepatic encephalopathy
what are the signs of ALF?
Presence of risk factors Hepatotoxic medication Jaundice Signs of hepatic encephalopathy Absence of chronic liver disease, splenomegaly, spider angiomata, palmar erythema or ascites Cerebral oedema
what are the symptoms of ALF?
Abdo pain Nausea Vomiting Malaise RUQ tenderness depression
what are the first line and gold standard investigations for ALF?
Liver function tests - hyperbilirubinemia, elevated liver enzymes
Prothrombin time - elevated
Basic metabolic panel - elevated urea and creatinine
FBC - leukocytosis, anaemia, thrombocytopenia
Blood type and screen
Arterial blood gas and lactate - acidosis and elevated
Paracetamol level
Urine toxicity
Factor v level - low
Viral hep serologies
Autoimmune hep markers
Pregnancy test
CXR
Abdo ultrasound with Doppler
liver biopsy
what are the differential diagnoses for ALF?
Severe acute hep, cholestasis, haemolysis
how is ALF managed?
ICU management, liver transplant assessment, neurological status monitoring, monitoring of blood glucose, electrolytes and cultures, acetylcysteine etc. TIPS, liver transplant
how is ALF monitored?
Intensive care unit monitoring during the course of hospitalisation is very important in the management of patients presenting with ALF, in order to provide optimal care and minimise complications. Following spontaneous recovery from ALF, patients should continue follow-up with their primary care and speciality care providers, including hepatologists
what are the complications of ALF?
Rapidly progressing hepatic encephalopathy, coagulation, infection, renal failure and haemodynamic changes
what is the prognosis of ALF?
Risk of mortality, higher prognosis for paracetamol overdose or acute hep A aetiology
