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Altered sensorium
Mushroom poisoning
Acetaminophen
Chemical agents
Drug-induced hepatitis
Budd-Chiari Syndrome
VOD of liver
Wilsons disease
AIH
ALF
Etiologies
Reactivation of HBV
Chemotherapy
Immunosuppresion
Herpes simplex
Varicella-Zoster
EBV
Acute HAV and ALF
ALF uncommon
Herbal remedies
Yellow phosphorus
Ischemic Hepatitis and ALF
Liver cell necrosis - massive
scale
Cardiac tamponade
Pulmonary embolus
Budd-Chiari syndrome
and thrombosis of hepatic
veins
Attributed to ischemic
changes
Leukemia, lymphoma
Malignant histiocytosis
Metastatic Replacement
Other Etiologic Causes of ALF
Wilsons Disease
AIH
May appear as an acute hepatitis
on initial presentation
More common if anti-LKMI antibody present
ASMA usually not present
Other Etiologies (3)
Hyperthermia (Heat stroke)
Direct thermal injury
Hepatic ischemia due to
-DIC
-Perfusion defect
OLT
Poor presentation of donor liver
Acute graft rejection
Thrombosis - hepatic artery, hepatic
vein, portal vein
Partial hepatectomy
Removal of 80% or more of healthy liver
Removal of 50% or less in hepatic dysfunction
Evaluation & Diagnosis
of Impending ALF
Sexual contacts
IDU
Risk Factors
Pregnancy Mushrooms
Onset of jaundice
Hobbies
Hepatic tenderness
Hepatic decompensation
Laboratory Tests
(1)
Drug screening
ALT, AST, Alk Phos, Glu,
Bilirubin
Lytes, Albumin, Mg, Phos.,
CBC with differential
Coags: PT, PTT
Anti HAV IgM
Anti HBc IgM/ Anti HBsAg/
Anti-HCV
Laboratory Tests
(2)
If under 35 years of age
Ceruloplasmin
Serum & urine copper
Arterial blood gas
Arterial lactate
Pregnancy test
Autoimmune markers ANA, ASMA, Ig
levels
HIV status
Amylase & lipase
Liver Biopsy
Reserved for diagnostic
dilemma -
AIH, HS
(Transjugular approach)
Diagnosis of ALF
Hallmarks - occurs simultaneously or in
succession
Altered mentation
Clinical
EEG
Arterial Ammonia
Coagulopathy
PT 4 sec prolonged (INR 1.5)
Arterial pH<7.3 if acetaminophen ingested
(cause for immediate transfer for OLT)
Management of ALF
(1)
Directed towards prevention of complications
ICU setting
Central line(s)-10% dextrose
Pulmonary artery pressure and CO
Inform Transplant Service and transfer with
onset of HE
Monitor VS and urinary output (Foley)
strict I&O
Laboratory Testing every 4-6hr
electrolytes, BUN, creatinine, CBC, platelets,
PT, PTT, ALT, AST, T. bilirubin, Alk Phos, Albumin
Management (2)
Imazaki, et al
When CPP<40 for 2 hrs. 0 of 7 patients recovered
When CPP>50 6 of 8 patients recovered
Improved ICP first sign of spontaneous recovery
Management (3)
Cerebral Edema & Intracranial Hypertension
(Most serious complications of ALF)
Gut leak
MOF Activation of
macrophages
Metabolic Complications
Prevent hypoglycemia
Phosphate and magnesium levels
monitored - replace early
Enteral feeding, 60gm protein/24 hrs
No role for high branched-chain AA
Monitor for lactic acidosis secondary to
tissue hypoxia, sepsis
Role of Cardiac Index
(CI = cardiac output/body surface area)
ARDS
Sepsis
- Severe complement deficiency
- Decreased PMN motility
- Decreased Kupffer cell function
and removal of endotoxins
- Increased levels of TNF and IL-6
Prognostic Factors
Dependent on Etiology
Transplantation
Temporary Measures
308 Patients
Alive Died
N=75 N=14
(84%) (16%)
Approach to Suspected ALF
Etiology and Pathogenesis
Complications
Management
Prognosis