Acute Liver Failure Flashcards by Andrew Kreutzer

Acute Liver Failure
Definition & Diagnosis

INR >/= 1.5
Any degree of mental alteration (encephalopathy) w/o pre-existing cirrhosis & illness < 26 weeks

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Most common causes of acute liver failure

drug-induced
viral hepatitis
autoimmune
shock

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What is the leading cause of acute liver failure?
How much is required?
What will labs reflect?

Acetaminophen
>10gm/d
very high LFTs low bilirubin

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What can cause acute liver failure if ingested?
What symptoms can this cause?

Wild mushrooms
N/V, diarrhea, abdominal cramping, hours - 1 day after ingestion

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Infectious causes of Acute Liver Failure

Hepatitis A, B, other viral hepatitis (infreq.)

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Other uncommon causes of acute liver failure

Acute fatty liver of pregnancy
Reye’s Syndrome
Wilson’s Disease
Acute ischemic liver injury (shock liver)
Budd-Chiari Syndrome (rare)

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Wilson’s disease is characterized by what?
Lab values will look like what?
Happens to what population?
Hemolytic anemia leads to what?

Copper accumulation
very high bili; low alk phos (bili:alk phos ratio > 2)
younger age
bili > 20 mg/dL, Keyser-Fleischer rings on slit lamp exam, elevated copper in blood, urine, & liver

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Acute ischemic liver injury (shock liver) will display what labs?

markedly elevated LFTs, LDH (necrosis) with rapid improvement

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Budd-Chiari Syndrome is characterized by what?

occlusion of hepatic veins

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Acute Liver Failure Physical Exam should check what?

Mental Status
+/- jaundice
RUQ tenderness
enlarged liver (acute viral hepatitis, malignancy, CHF, acute Budd-Chiari syndrome)

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Stage 1 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

0-24 hrs
Preclinical
General malaise, N/V. diffuse abd pain, possibly asymptomatic, minimal s/sx, normal liver function tests, possibly

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Stage 2 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

24-72 hrs
Hepatotoxicity
RUQ pain possibly, clinically asymptomatic possibly, AST and ALT begin to rise, and possibly bilirubin, coagulopathy studies (PT, PTT, INR) may increase if severe injury

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Stage 3 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

72-96hrs
Hepatic failure with encephalopathy
LFT peak, clinical s/sx of liver failure are evident, including: jaundice, vomiting, GI upset, coagulopathy, encephalopathy, metabolic acidosis, pancreatitis possibly, acute renal failure possibly

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Stage 4 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

> 96hrs
Survival or death
Full resolution of hepatotoxicity or Multi-organ failure and death

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Cerebral edema
Develops in what % of FHF with grade IV encephalopathy?
NH4 level < 75: rarely develops what?
>100: risk factor for what?
> 200: associated with what?
leading cause of what in FHF?
Results from what?

65-75%
ICH
high grade encephalopathy
cerebral herniation
death
ammonia’s direct/indirect toxic effects on the brain

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Acute Liver Failure Lab Work up includes?

PT/INR
Chem: CMP, GGT, total bili, albumin creatinine
ABG
Lactate
CBC
Blood type and Screen
Acetaminophen level
Tox screen
Viral hepatitis serologies
Ceruloplasmin level
pregnancy test
ammonia level
autoimmune markers
HIV 1&2
Amylase and lipase

Viral hepatitis serologies include?

Anti-HAV IgM
HBsAg
anti-HBc IgM
anti-HEV
Anti-HCV
HCV RNA
HSV IgM
VZV

Autoimmune Markers include?

ANA
ASMA
Immunoglobulin levels

Viral Hepatitis
ALT/AST
Bilirubin
Alk phos
albumin
INR

increased
/
/
decreased
increased

ETOH hepatitis
ALT/AST
Bilirubin
Alk phos
albumin
INR

Increased
/
/
/
Increased

Biliary obstruction
ALT/AST
Bilirubin
Alk phos
albumin
INR

/
Elevated
elevated
/
/

Cirrhosis
ALT/AST
Bilirubin
Alk phos
albumin
INR

elevated
/
/
decreased
elevated

Wilson Dz
ALT/AST
Bilirubin
Alk phos
albumin
INR

/
Elevated
decreased
/
/

Acetaminophen toxicity
ALT/AST
Bilirubin
Alk phos
albumin
INR

elevated
decreased
/
/
elevated

When etiology of ALF cannot be determined after routine evaluation do what? It may ID what?

Liver bx malignancy, autoimmune hepatitis, viral infection, wilson dz

Management of Acute Liver Failure Hospital admission if? ICU admission if?

any alteration in mental status any degree of encephalopathy & referral to transplant center

Acetaminophen toxicity management If < 8 h after ingestion Give what? for how long? If labs abnormal do what?

N-acetylcycseine 150mg/kg/h x 1h --> 12.5mg/k/h x 20 hr --> if acet level is 0, LFTs NL, and patient is well DC Continue @ 12.5mg/kg/h until lab & clinical improvement (50% decrease in LFTs from peak, INR < 2)

Acetaminophen toxicity management If > 8 h after ingestion Give what? for how long? If labs abnormal do what?

N-acetylcysteine 150mg/k/hr x1 hr --> 12.5mg/k/h x >/=36h --> if ace level 0, LFTs NL, and patient is well DC continue @ 12.5 mg/k/hr until lab & clinical improvement (50% decrease in LFTs from peak, INR < 2) tox consult

Severe or acute encephalopathy Admit where? Give what?

ICU lactulose rifaximin

Lactulose how effective when compared to chronic encephalopathy? How does it work? Goal is what?

less effective increases stool acidity, trappin NH4 ions ~800-1000ml of stool/day

Rifaximin reduces ammonia production by what means?

reducing ammonia producing colonic bacteria

Cerebral Edema Management reduce what? Increase what? what type of monitoring? Maintain CPP of what? Support other organ systems such as? Give what in early encephalopathy?

stimulation serum osmolality (HTN saline, mannitol) +/- ICP monitoring > 60 mmHg acid/base, electrolyte, dialysis, ventilator, ect. lactulose

Liver Transplant Criteria for Status 1 listing (in addition to care in ICU include 1 of the following:

vent dependence hemodialysis or hemofiltration INR > 2 in pt with onset of hepatic encephalopathy w/n 8 wks of initial symptoms of liver dz

Outcomes in ALF are worse in 1st postop year compared to recipients w/ chronic liver dz d/t what? Beyond 1 yr how are their survival rates compared to chronic liver dz?

infectious & neuro complications they surpass survival rates for chronic liver dz