Makindo Medical Notes

Related Subjects: |Chronic liver disease |Liver Function Tests |Ascites Assessment and Management |Budd-Chiari syndrome |Alcoholism and Alcoholic Liver Disease |Liver Transplantation

⚠️ Acute Liver Failure (ALF) is acute primary liver dysfunction in a patient without pre-existing chronic liver disease. In hyperacute cases, jaundice-to-encephalopathy develops within <1 week (often due to paracetamol toxicity or viral hepatitis A, B, E). Red flags: coagulopathy, high transaminases, ↑ bilirubin, and altered consciousness → may progress to coma & death.

Classification: Jaundice → Encephalopathy Interval

About

• 📊 Incidence: ~10 cases/million/year (developed countries).
• 👩 Typically affects young, previously healthy adults.
• Fulminant hepatic failure: encephalopathy within 8 weeks of symptoms, no prior liver disease.
• 🔎 Diagnostic criteria: Injury <26 weeks, INR >1.5, altered mental status, no cirrhosis.

Key Findings

• 🟡 Jaundice, elevated bilirubin.
• 📈 ALT/AST very high.
• 🩸 Coagulopathy (↑ PT/INR).
• 🧠 Encephalopathy: confusion → coma.

Causes of ALF

• 🦠 Viral (40–70%): HAV, HBV, HCV, HDV, HEV, EBV, CMV, HSV.
• 💊 Drugs/Toxins (20%): Paracetamol (UK’s most common), isoniazid, phenytoin, halothane, ecstasy.
• 🛡️ Autoimmune hepatitis.
• 🔬 Metabolic: Wilson’s disease, acute fatty liver of pregnancy.
• 🩺 Vascular: Budd–Chiari syndrome.
• 🤰 Pregnancy-related: HELLP syndrome.
• 🐀 Others: Leptospirosis, yellow fever, Reye’s syndrome (aspirin in children).
• ❓ 20–30% remain idiopathic.

Clinical Features

• 📖 History: Drug exposure, toxins, infection.
• 🤢 Symptoms: Jaundice, nausea, bleeding, hypoglycaemia.
• 🧠 Encephalopathy signs: Asterixis, fetor hepaticus, apraxia.
• Stigmata of chronic disease usually absent.
• Grades of encephalopathy: 1 = disoriented → 4 = coma.

Investigations

• 🧪 Bloods: FBC, U&E, LFT, clotting, ABG (metabolic acidosis), ammonia, viral serology, autoimmune screen, Wilson’s tests, pregnancy test, HIV.
• 🖥️ Imaging: Liver USS + Doppler (exclude Budd–Chiari).
• 🧫 Consider biopsy if unclear cause & coagulopathy corrected.

General Management

• 🛌 Admit to high-dependency/ICU; involve hepatology early.
• 🔄 ABC support: oxygen, IV fluids, airway if encephalopathy ≥3.
• 🍬 IV dextrose infusion for hypoglycaemia.
• 🩸 Coagulopathy: Vitamin K, FFP/platelets if bleeding or invasive procedures.
• 💩 Lactulose for encephalopathy (2–3 soft stools/day).
• 🧠 Prevent ↑ ICP: head up 20°, avoid hypotension/hypoxia, mannitol if cerebral oedema.
• 🚑 Early referral to liver transplant centre if criteria met.

Cause-Specific Management

• 💊 Paracetamol overdose → IV N-acetylcysteine (NAC) immediately.
• 🛡️ Autoimmune hepatitis → steroids (e.g. prednisolone) if infection excluded.
• 🍄 Mushroom (Amanita) → IV penicillin G ± silymarin; urgent transplant eval.
• 🤰 Pregnancy: Deliver fetus (acute fatty liver, HELLP).
• 🧬 Wilson’s disease → urgent transplant.
• 🦠 Viral hepatitis → supportive ± antivirals in selected cases (HSV, HBV).
• 🩸 Budd–Chiari → anticoagulation, thrombolysis, shunt, or transplant.

Complications

• ⚡ Hypoglycaemia.
• 🩸 Coagulopathy & bleeding.
• 🧠 Cerebral oedema → herniation risk.
• 🧬 Infections (sepsis risk high).
• ⛑️ Renal failure (Hepatorenal syndrome).

References

• EASL Clinical Practice Guidelines (2017)
• NEJM Review: Acute Liver Failure (2013)