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| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Acute liver failure resident survival guide]]|| <br> || <br> |
| | | [[Acute liver failure resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = |
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| ICD10 = {{ICD10|K|72|9|k|70}} |
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| ICD9 = |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| MeshID = D017114 |
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| }}
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| {{Acute liver failure}} | | {{Acute liver failure}} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh@perfuse.org], [[User: Prashanthsaddala|Prashanth Saddala M.B.B.S]] | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{HS}}, [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com], {{ADI}} |
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| | {{SK}} ALF, acute hepatic failure, fulminant hepatic failure, fulminant liver failure, fulminant hepatitis |
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| | ==[[Acute liver failure overview|Overview]]== |
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| | ==[[Acute liver failure historical perspective|Historical Perspective]]== |
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| | ==[[Acute liver failure classification|Classification]]== |
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| | ==[[Acute liver failure pathophysiology|Pathophysiology]]== |
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| | ==[[Acute liver failure causes|Causes]]== |
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| ==Diagnosis== | | ==[[Acute liver failure differential diagnosis|Differentiating Acute Liver Failure from other Diseases]]== |
| ===History ===
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| History taking should include careful review of possible exposures to viral infection and drugs or other toxins.
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| ===Symptoms===
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| *[[Nausea]] or [[vomiting]]
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| *[[Loss of appetite]]
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| *[[Fatigue]]
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| *[[Diarrhea]]
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| *[[Jaundice]]
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| *[[Bleeding]] easily
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| *Swollen abdomen
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| *[[Disorientation]] or [[confusion]]
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| *[[Sleepiness]], even [[coma]]
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| ===Physical Examination===
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| From history and clinical examination possibility of underlying chronic disease should be ruled out as it may have different management.
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| ===Laboratory tests===
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| All patients with clinical or laboratory evidence of moderate to severe acute hepatitis should have immediate measurement of prothrombin time and careful evaluation of mental status. If the prothrombin time is prolonged by ≈ 4-6 seconds or more (INR ≥1.5)
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| and there is any evidence of altered [[sensorium]], the diagnosis of ALF should be strongly suspected and hospital admission is mandatory<ref name="Polson">{{cite journal |author=Polson J, Lee WM |title=AASLD position paper: the management of acute liver failure |journal=Hepatology |volume=41 |issue=5 |pages=1179-97 |year=2005 |pmid=15841455 |doi=10.1002/hep.20703}}</ref>. Initial laboratory examination must be extensive in order to evaluate both the aetiology and severity.
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| ;Initial laboratory analysis<ref name="Polson"/>
| | ==[[Acute liver failure epidemiology and demographics|Epidemiology and Demographics]]== |
| *[[Prothrombin time]]/INR
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| *[[Complete blood count]]
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| *Chemistries
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| **Liver function test: [[Aspartate transaminase|AST]], [[Alanine transaminase|ALT]], [[alkaline phosphatase]], [[Gamma-glutamyl transpeptidase|GGT]], total [[bilirubin]], [[albumin]]
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| **[[Creatinine]], urea/[[blood urea nitrogen]], sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate
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| **[[Blood sugar|glucose]]
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| **[[Amylase]] and [[lipase]]
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| *[[Arterial blood gas]], [[lactate]]
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| *Blood type and screen
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| *[[Paracetamol]] (Acetaminophen) level, Toxicology screen
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| *[[Viral hepatitis]] serologies: anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HEV
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| *[[Autoimmune]] markers: [[Anti-nuclear antibody|ANA]], [[Anti-actin antibodies|ASMA]], LKMA, [[Antibody|Immunoglobulin]] levels
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| *[[Ceruloplasmin]] Level ( when Wilson's disease suspected)
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| *[[Pregnancy test]] (females)
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| *[[Ammonia]] (arterial if possible)
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| *[[HIV]] status (has implication for [[transplantation]])
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| ====Liver Biopsy====
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| A [[liver biopsy]] done via the [[jugular|transjugular]] route because of [[coagulopathy]] is not usually necessary other than in occasional malignancies.
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| As the evaluation continues, several important decisions have to be made such as whether to admit the patient to an ICU, or whether to transfer the patient to a transplant facility. Consultation with the transplant centre as early as possible is critical due to possibility of rapid progression of ALF.
| | ==[[Acute liver failure risk factors|Risk Factors]]== |
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| ==Treatment== | | ==[[Acute liver failure screening|Screening]]== |
| {|style="padding:0.3em; float:right; margin-left:5px;border:1px solid #ffa508;"
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| |-style="background-color:#FFE4E1; align:center; color:#8B4513; text-align: center"
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| |'''King's College Hospital criteria''' <br />
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| '''for liver transplantation in acute liver failure<ref>{{cite journal |author=O'Grady JG, Alexander GJ, Hayllar KM, Williams R |title=Early indicators of prognosis in fulminant hepatic failure |journal=Gastroenterology |volume=97 |issue=2 |pages=439-45 |year=1989 |pmid=2490426 |doi=}}</ref>'''
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| |'''Patients with [[paracetamol]] toxicity'''<br />
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| pH <7.3 or<br />
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| [[Prothrombin time]] >100 seconds and<br /> [[serum creatinine]] level >3.4 mg/dL (>300 μmol/l)<br />
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| if in grade III or IV [[hepatic encephalopathy|encephalopathy]]
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| |-
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| |'''Other patients'''<br />
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| Prothrombin time >100 seconds or <br />
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| ''Three of the following variables'':<br />
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| *Age <10 yr or >40 yr
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| *Cause:
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| ** non-A, non-B hepatitis
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| ** [[halothane]] hepatitis
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| ** idiosyncratic drug reaction
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| *Duration of jaundice before encephalopathy >7 days
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| *prothrombin time >50 seconds
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| *Serum [[bilirubin]] level >17.6 mg/dL (>300 μmol/l)
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| |}
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| ===Aim of therapy is to correct=== | |
| * Metabolic abnormalities
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| * Coagulation defects
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| * Electrolyte and acid-base disturbances
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| * Advanced chronic kidney disease
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| * Hypoglycemia
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| * Encephalopathy
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| ===Treatment strategies===
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| ====General measures====
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| * Treatment involves admission to hospital; often [[intensive care unit]] admission or very close observation are required.
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| * Supportive treatment with adequate nutrition and, optimization of the [[fluid balance]] should be done
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| * [[Mechanical ventilation]], [[intubation]] is indicated for stage 3 or 4 encephalopathy
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| * [[Sepsis]] and infections are common with [[fulminant liver failure]]. Though prophylactic antibiotic decreases the risk of infection, but is not routinely recommended as no survival benefits have been proved. Nevertheless, broad coverage with antibiotics is recommended for suspected cases of sepsis.
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| * Routine administration of steroids for [[adrenal insufficiency]] is not recommended.
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| * [[H2 receptor blocker]] and [[proton pump inhibitors]] are indicated to prevent and treat [[stress gastropathy]].
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| * Early transfer to a liver transplantation center should be decided based on patient's clinical status.
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| ====Management of increased intracranial pressure==== | | ==[[Acute liver failure natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * [[Intracranial pressure]] monitoring in severe encephalopathy and impending cerebral edema should be done with extradural sensors
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| * The goal should be to maintain the intracranial pressure below 20 mm Hg and the cerebral perfusion pressure above 70 mm Hg.
| | ==Diagnosis== |
| * [[Lactulose]] is indicated in cases of encephalopathy.
| | [[Acute liver failure diagnostic study of choice|Diagnostic Study of Choice]] | [[Acute liver failure history and symptoms|History and Symptoms]] | [[Acute liver failure physical examination|Physical Examination]] | [[Acute liver failure laboratory findings|Laboratory Findings]] | [[Acute liver failure x ray|X Ray]] | [[Acute liver failure CT|CT]] | [[Acute liver failure echocardiography or ultrasound|Ultrasound ]] | [[Acute liver failure other imaging findings|Other Imaging Findings]] | [[Acute liver failure other diagnostic studies|Other Diagnostic Studies]] |
| * Mannitol, 0.5 g/kg, or 100–200 mL of a 20% solution by intravenous infusion over 10 minutes for reducing cerebral edema
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| * [[Mannitol]] should be avoided in patients with advanced chronic kidney diseases.
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| * Hypernatremia (145-155 mEq/L) through intravenous hypertonic saline infusion to induce hypernatremia may be used to reduce intracranial hypertension.
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| * Hypothermia (32–34 °C) may reduce intracranial pressure in refractory cases can be tried.
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| * Other measures like elevation of head end to 30 degrees, hyperventilation and intravenous prostaglandin E1can also be used.
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| * Short-acting barbiturate, propofol, or i/v indomethacin for refractory intracranial hypertension.
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| ===Treatment for specific underlying cause===
| | ==Treatment== |
| ====Acetaminophen or Paracetamol poisoning====
| | [[Acute liver failure medical therapy|Medical Therapy]] | [[Acute liver failure surgery|Surgery]] | [[Acute liver failure primary prevention|Primary Prevention]] | [[Acute liver failure secondary prevention|Secondary Prevention]] | [[Acute liver failure cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Acute liver failure future or investigational therapies|Future or Investigational Therapies]] |
| ** [[Acetylcysteine]] for [[paracetamol poisoning]] up to 72 hours after ingestion
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| ** It improves cerebral blood flow and increases transplant-free survival in patients with stage 1 or 2 [[encephalopathy]] due to hepatic failure of any cause.
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| ** Its treatment can increase [[prothrombin time]] giving a false alarm of worsening liver failure.
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| *** 140 mg/kg orally followed by 70 mg/kg orally every 4 hours for an additional 17 doses or
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| *** 150 mg/kg in 5% dextrose intravenously over 15 minutes followed by 50 mg/kg over 4 hours and then 100 mg/kg over 16 hours
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| ====Mushroom poisoning====
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| * Penicillin G - 300,000 to 1 million units/kg/day or
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| * Silibinin/silymarin/milk thistle (not licensed in the United States)
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| ====Chronic viral hepatitis====
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| * Nucleoside analogs - Fulminant hepatitis B
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| ====Herpes simplex hepatitis====
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| * Intravenous acyclovir
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| ====Wilson disease====
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| * [[Plasmapheresis]] + [[D-penicillamine]]
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| ===Other supportive measures=== | | ==Case Studies== |
| * Drainage of [[ascites]].
| | :[[Acute liver failure case study one|Case #1]] |
| * While many people who develop acute liver failure recover with supportive treatment, [[liver transplant]]ation is often required in people who continue to deteriorate or have adverse [[Prognosis|prognostic]] factors.
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| * "[[Liver dialysis]]" (various measures to replace normal liver function) is evolving as a treatment modality and is gradually being introduced in the care of patients with liver failure.
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| ==References==
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| {{Reflist|2}}
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| [[Category:Organ failure]]
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| [[Category:Causes of death]]
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| [[Category:Hepatology]] | | [[Category:Hepatology]] |
| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Intensive care medicine]]
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| [[it:Insufficienza epatica fulminante]]
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| [[pl:Ostra niewydolność wątroby]]
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| [[ur:فشل جگری خاطف]]
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