Acute Liver Failure

See also Coma
See Chronic liver failure

Hepatic encephalopathy = abnormal liver function + altered mental state (+/- asterixis & constructional apraxia)

Usually due to de-compensated chronic liver failure - LOOK for an acute precipitant
Acute causes in previously well patient from hepatotoxin - paracetamol, Amanita mushroom, halothane

RESUSCITATION

AIRWAY

Intubate if GCS < 8 or massive variceal bleeding

BREATHING

Ventilate if GCS < 8 or inadequate ventilation

CIRCULATION

Fluid resuscitate for massive variceal bleeding or septicaemic

DISABILITY

If comatose consider treatment for cerebral oedema
Check BSL (from decreased hepatic glucose stores)

EVALUATE PRECIPITANT

See also Coma

CAUSE	CLINICAL FEATURES	INVESTIGATION
Infection (consider spontaneous bacterial peritonitis in ascites)	see Infective sources	WCC Septic screen +/- ascitic tap (WCC > 200/cmm)
Electrolyte abnormalities		EUC/Calcium
Uraemia	see Renal failure	EUC
Variceal bleeding	Haematemesis/Malaena	Urea, Hb
CNS depressants	Hx of opiate/sedative/psychotropic use

ASSESS SEVERITY

Grade	GCS	Pupils	Reflexes	Other findings
I	14-15	Normal		Abnormal cognition Asterixis Constructional apraxia
II	12	Normal	Hypertonic	Hyperventilation
III	9-11	Hyperreactive Hippus	Clonus Upgoing plantars	Agitation
IV	6-7	Hyporreactive Hippus	Flaccid
Coning	3	Fixed/Dilated

FURTHER INVESTIGATIONS

Determined by clinical presentation

LFTs
INR
Serum ammonia (collect in red tube on ice)
Paracetamol level (if ingestion possible)
CT brain - if evidence of head injury, focal signs or no other cause found

DEFINITIVE MANAGEMENT

Lactulose 20ml qid PO (PR if upper GI bleed)
?Flumazenil
?N-acetyl cysteine
?Artificial liver haemo-perfusion

Neomycin PO no longer used

DISPOSAL

Admit to HDU/ICU if:

Variceal bleeding
Septicaemic shock
GCS < 12
Elderly/Co-morbidities/Complications

Admit all others to ward

PROGNOSIS - Child-Pugh classification

Grade		A	B	C
Clinical	Ascites Encephalopathy	- -	+ Grade I-II	+++ Grade III-IV
Investigation	Albumin (g/L) Bilirubin (umol/L) INR	>35 < 36 < 1.3	30-35 36-55 1.3 - 1.5	< 30 > 55 > 1.5
Operative mortality		2%	10%	50%

With acute oesophageal bleed = 50%

Recurrence rate 2/3