1. Acute Liver Failure Tutorial Ayman Abdo

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 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

6. Acute Liver Failure Definition 1. Rapid hepatocellular dysfunction 2. Encephalopathy 3. No pre-existing liver disease

7. Common causes of acute liver failure Viral hepatitis: Hep A, Hep B Toxin/drugIschemic Autoimmune hepatitis Wilson disease

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

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

10. 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

11. 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

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

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

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

15. 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

16. Causes of acute liver failure Viral hepatitis: Hep A, Hep B Toxin/drugIschemic Autoimmune hepatitis Wilson disease

20. Lab investigations CBCElectrolytes 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

21. Pattern in Ischemic hepatitis

22. Ischemic vs. viral

23. Get more information ?

24. Complications & Management

26. Specific therapy Viral:Ischemic:Toxic: Acetaminophen (N-acetyl cystein) AutoimmuneWilson

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

28. King’s College Criteria 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 40 yrs –Bili > 300 –Coagulopathy: INR > 3.5 –Duration of jaundice > 7 days before HE –Etiology: Non A-E, other drug O’Grady et al. Gastroenterology 1989;97:439

30. MARS : Molecular adsorbents recycling system

32. What is the best way to prevent acute fulminant liver failure?

33. درهم وقاية خير من قنطار علاج

34. What is the best way to reduce the incidence of acute fulminant liver failure?

35. Prevention HBV Vaccination HAB vaccination Avoid herbs Careful with drugs Clean food Sexual practices Volume ressiciatation

38. More quick cases

39. 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

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

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

42. Patient 2 How would you manage this patient?

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

44. Patient 3 What is the most likely cause?

45. Patient 3 How would you manage this patient?

46. 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

47. Patient 4 What is the most likely cause?

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

49. 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