1. Acute liver failureTutorial AymanAbdoMD, FRCPC

2. Objectives After the discussion in this educational exercise, I want you to be able to : • Identify common causes of acute liver failure through history and examination • Recognize common presentations • Be familiar with medical management • Know when to refer a patient for transplantation

4. Acute Liver FailureDefinition • Rapid hepatocellular dysfunction • Encephalopathy • No pre-existing liver disease

5. Common causes of acute liver failure • Viral hepatitis: Hep A, Hep B • Toxin/drug • Ischemic • Autoimmune hepatitis • Wilson disease

6. Pt 1: Initial history • 66 y old female • Chronic abdominal pain and constipation • Otherwise healthy • 3 day history of jaundice and confusion

7. Patient 1 What other questions are you going to ask?

8. 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

9. 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

10. Patient 1 What physical signs are you going to look for?

11. Physical examination • Vital signs • Level of conciseness • Flapping tremor • Stigmata of chronic liver disease • Ophthalmology exam if indicated • Full abdominal examination • Full neurological examination

12. Patient 1 What labs are you going to order?

13. 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

14. Causes of acute liver failure • Viral hepatitis: Hep A, Hep B • Toxin/drug • Ischemic • Autoimmune hepatitis • Wilson disease

18. 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

19. Pattern in Ischemic hepatitis

20. Ischemic vs. viral

21. Get more information ?

22. Complications&Management

24. Specific therapy • Viral: • Ischemic: • Toxic: Acetaminophen (N-acetyl cystein) • Autoimmune • Wilson

25. Which pt will recover with intensive medical therapy and which pt requires transplantation?

26. 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 King’s College Criteria O’Grady et al. Gastroenterology 1989;97:439

29. MARS : Molecular adsorbents recycling system

31. More quick cases

32. 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

33. Patient 2 What are the possible causes of this presentation?

34. Case 2 • No physical signs except for jaundice • No encephalopathy • ALT=2300, AST=1700, ALP=480, GGT=789, INR=2.1

35. Patient 2 How would you manage this patient?

36. Patient 3 • 55 y old male • Massive acute MI • Successful resuscitation • Cardiac condition stable • 5 days later: ALT=2300, AST=2000, LDH=4500

37. Patient 3 What is the most likely cause?

38. Patient 3 How would you manage this patient?

39. 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

40. Patient 4 What is the most likely cause?

41. Patient 4 • Cerulopasmin= very low • 24 urinary cupper= very high • Ophthalmology exam= KFR

42. 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