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fuliminant hepatic failure

Etiology: 1) drug hepatotoxicity a) acetaminophen toxicity, ingestion > 4 grams; lower amounts may be associated with alcoholism b) isoniazid c) sulfonamides d) tetracycline e) NSAIDs 2) drugs of abuse: a) MDMA (Ecstasy) b) cocaine 3) pharmaceutical herbs a) black cohosh b) chaperral 4) Amanita poisoning 5) virus infections a) hepatitis A, hepatitis B, hepatitis E b) Herpes viruses - Herpes simplex - cytomegalovirus, - Epstein-Barr virus - Varicella-zoster c) parvovirus B19 5) bacterial infection: Bacillus cereus 6) Budd-Chiari syndrome 7) pregnancy disorders a) acute fatty liver of pregnancy b) HELLP syndrome 8) autoimmune hepatitis Clinical manifestations: 1) acute liver failure 2) coagulopathy 3) encephalopathy Radiology: - CT of head for to look for intracerebral hemorrhage Laboratory: 1) PT/PTT abnormal 2) liver function tests may be abnormal a) serum AST elevated b) serum ALT elevated 3) plasma NH3 may be elevated 4) serum acetaminophen 5) hepatitis A serology 6) hepatitis B serology 7) do NOT perform liver biopsy a) dangerous b) not associated with improved outcomes Management: 1) fresh frozen plasma for coagulopathy 2) arteriovenous hemofiltration with or without hemodialysis supports renal function 3) lactulose for encephalopathy 4) mannitol for elevated intracranial pressure a) corticosteroids not indicated b) barbiturate-induced coma not indicated c) contraindicated in renal failure 5) N-acetyl cysteine for acetaminophen toxicity 6) liver transplantation - transplantation centers monitor intracranial pressure for cerebral edema due to hepatic encephalopathy 7) mechanical liver assistance does not extend survival

General

acute liver failure (ALF)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14, 16. American College of Physicians, Philadelphia 2006, 2012
  2. O'Grady JG et al, Fulminant hepatic failure. In: Diseases of the Liver, Schiff L, Schiff R (eds), JB Lippincott, Philadelphia 1993
  3. Ichai P, Samuel D. Etiology and prognosis of fulminant hepatitis in adults. Liver Transpl. 2008 Oct;14 Suppl 2:S67-79 PMID: 18825677