Transcript ALF tutorial

Acute liver failure
Tutorial
Ayman Abdo MD, FRCPC
Objectives
To identify common causes of acute liver
failure through history and examination
To recognize common presentations
To be familiar with medical management
To know when to refer a patient for
transplantation
Acute Liver Failure
Definition
1. Rapid hepatocellular
dysfunction
2. Encephalopathy
3. No pre-existing liver
disease
Common causes of acute liver failure
Viral hepatitis: Hep A, Hep B
Toxin/drug
Ischemic
Autoimmune hepatitis
Wilson disease
Pt 1: Initial history
66 y old female
Chronic abdominal pain and constipation
Otherwise healthy
3 day history of jaundice and confusion
Patient 1
What other questions
are you going to ask?
Important questions on history
Recent travel
Sexual exposure
IVDU
Contact with jaundiced pt
Detailed drug history including herbs
Autoimmune features
Neurological symptoms
Recent hypotension or sepses
Pt 1 : More history
Dx to have IBS
Started on herbal medication 1 week ago
No viral hepatitis risk factors
No hypercoagulable disorder
No new medications
Patient 1
What physical signs are
you going to look for?
Physical examination
Vital signs
Level of conciseness
Flapping tremor
Stigmata of chronic liver disease
Ophthalmology exam if indicated
Full abdominal examination
Full neurological examination
Patient 1
What labs are you going
to order?
Important labs
CBC and electrolytes
Liver enzymes : ALT, AST, ALP, GGT, LDH
Liver function tests: INR, Albumine, Bili
Viral hep serology= HAV IgM, Hep B cAb IgM,
HCV RNA
Toxic screen: Acetaminophen level
AIH markers: ANA, ASMA
Wilson: Ceruloplasmin, urine cupper
Others
Causes of acute liver failure
Viral hepatitis: Hep A, Hep B
Toxin/drug
Ischemic
Autoimmune hepatitis
Wilson disease
Lab investigations
CBC
Electrolytes
Liver enzymes (ALT, AST, ALP, GGT, LDH)
Liver function tests (Bili, Albumin, INR)
Hep A (IgM, IgG), Hep B (HBsAG, HBcIgM)
Acetaminophen level
ANA
Cerulopasmin, 24 h copper collection
Pattern in Ischemic hepatitis
Ischemic vs. viral
Get more information ?
Complications
&
Management
Specific therapy
Viral:
Ischemic:
Toxic:
Acetaminophen (N-acetyl cystein)
Autoimmune
Wilson
Which pt will recover with
intensive medical therapy and
which pt requires
transplantation?
King’s College Criteria
Acetaminophen
pH < 7.3
or
Grade III or IV HE
and
– INR > 6.5
– Creatinine > 300
Non-acetaminophen
INR > 6.5
or any 3/6
–
–
–
–
Age <10 or >40 yrs
Bili > 300
Coagulopathy: INR > 3.5
Duration of jaundice
> 7 days before HE
– Etiology: Non A-E, other drug
O’Grady et al. Gastroenterology 1989;97:439
MARS : Molecular adsorbents
recycling system
More quick cases
Case 2
A 33 y old female
Just came back from Umrah
Has 2 day history of dark urine and yellow
eyes
No new medications
Patient 2
What are the possible
causes of this
presentation?
Case 2
No physical signs except for jaundice
No encephalopathy
ALT=2300, AST=1700, ALP=480,
GGT=789, INR=2.1
Patient 2
How would you manage
this patient?
Patient 3
55 y old male
Massive acute MI
Successful resuscitation
Cardiac condition stable
5 days later: ALT=2300, AST=2000,
LDH=4500
Patient 3
What is the most likely
cause?
Patient 3
How would you manage
this patient?
Patient 4
22 y old male
Previously healthy
1 week history of jaundice
ALT=1500, AST=3400, ALP=450, INR=1.8
CBC= HB=7.8, WBC=10.8, PLt=340
Patient 4
What is the most likely
cause?
Patient 4
Cerulopasmin= very low
24 urinary cupper= very high
Ophthalmology exam= KFR
Conclusion
The most important three causes of acute liver
failure are : viral hepatitis, toxic hepatitis, and
ischemic hepatitis
Less likely causes include: Autoimmune
hepatitis, Wilson disease, malignant infiltration
Early recognition and treatment of the cause
Medical management of complication
Decide early about transplantation