inpatient / gastroenterology

Acute Liver Failure

Last Updated: 12/29/2022

# Acute Liver Failure

-- ABCs: 
to ICU for intubation if somnolent, need for pressors
-- Chart Check: previous liver disease (not acute liver failure), previous LFTs
-- HPI Intake: meds, tylenol use, supplements, timing of ingestion, clotting history, travel history, IVDU, sexual exposures, h/o cancer; FHx autoimmune disease
-- Can't Miss: need for intubation, increased ICP and hernitation
-- Admission Orders: strict I/O, q2-4 neurochecks, Labs: CBC, BMP, LFTs, coags, lactate, ABG, NH3, HIV, acetaminophen level, UDS, hepatitis serologies, IgG, ANA, ASMA, anti-LKM-1, amylase/lipase, RUQUS with doppler
-- Initial Treatment to Consider: give NAC in most situations, reverse elevated INR if able, consider vitamin K

-- History: *** OTC and herbal meds, travel, IVDU, sexual exposures, immunocompromised
-- Clinical: *** AMS, fatigue, lethargy, anorexia, N/V, RUQ pain, pruritis
-- Exam: *** AMS, jaundice, asterixis, RUQ pain
-- Data: *** AST/ALT, Tbili, INR, RUQUS
-- Etiology/DDx: *** tylenol, hepatitis, shock liver, Budd-Chiari, VOD s/p HSCT, AIH, Wilson, HELLP, HLH, malignant infiltration

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- Monitoring: *** (labs, seizures, hypoglycemia, infection, bleeding)
-- f/u labs - CBC, BMP, LFTs, coags, lactate, ABG, NH3, HIV, Acetaminophen level, tox screen, hepatitis serologies, IgG, ANA, ASMA, anti-LKM-1, amylase/lipase
-- f/u RUQUS with dopplers
-- f/u Liver consult for OLT evaluation

-- Medications: *** NAC 150mg/kg 1 hr → 12.5mg/kg 4 hrs → 6.25mg/kg 67 hrs; antivirals for HBV/HSV/VZV; steroids for AIH; TIPS for Budd-Chiari
-- Volume: *** 
-- Pressor: *** (start with levo, then add vaso)
-- If severe HE, consider hypertonic saline to keep Na 145-155, HOB at 30 degrees, and consider IV mannitol if c/f cerebral edema

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If You Remember Nothing Else

Acute liver failure has an unintuitive definition - encephalopathy and coagulopathy (INR >1.5) within a 26 week time frame, and without underlying liver disease. The most common cause is tylenol use - NAC should be given ASAP in most situations even if tylenol use is not suspected. Get the liver team involved early for consideration of transplant as this is often the only option for patients.

Clinical Pearls

  • Acute Liver Failure (ALF) is defined by encephalopathy and coagulopathy with INR >1.5 less than 26 weeks in patients without cirrhosis or underlying liver disease (otherwise it is considered acute on chronic liver failure)
  • Acute liver failure is within 26 weeks; fulminant is 1-3 weeks, hyperacute is within 1 week
  • Survival with liver transplant: ∼ 65–84% at 1 year
  • Complications - HE, cerebral edema, shock, pulm edema, ARDS, GID, pancreatitis, hypoglycemia, adrenal insufficiency, AKI, hyponatremia, coagulopathy, IDC, infection 
  • Giving lactulose for hyperammonemia is controversial
  • King’s College criteria for risk stratification - helps with deciding on OLT - if Tylenol, pH < 7.3, INR >6.5, Cr >3.4, HE

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