Acute liver failure (ALF) is a rare condition defined as a rapid deterioration of liver function resulting in altered mental status and coagulopathy in individuals without pre-existing liver disease within 26 weeks. It carries a high mortality and often affects young persons. The document discusses the causes, clinical presentation, complications, diagnosis, and management of ALF including supportive care, specific treatments, liver transplantation, and prognosis.
Acute kidney injury (AKI) is a potentially life-threatening
syndrome that occurs primarily in hospitalized patients
and frequently complicates the course of critically ill
patient.
Acute Kidney Injury is is (abrupt) reduction in kidney functions as evidence by changed in laboratory values; serum creatinine, blood urea nitrogen(BUN)and urine output
Acute kidney injury (AKI) is a potentially life-threatening
syndrome that occurs primarily in hospitalized patients
and frequently complicates the course of critically ill
patient.
Acute Kidney Injury is is (abrupt) reduction in kidney functions as evidence by changed in laboratory values; serum creatinine, blood urea nitrogen(BUN)and urine output
lupus nephritis is a autoimmune disease, commonly seen in adult and child and the medical or nursing care is also very important for this type of disease condition.
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
This is a lecture note for 5th semester MBBS students. Lecture notes on hepatology, liver disease, alcoholic liver disease, alcohol-related liver disease, portal hypertension, hepatic encephalopathy, and acute liver failure. Introduction to acute liver failure, causes, approach, and management of acute liver failure .
lupus nephritis is a autoimmune disease, commonly seen in adult and child and the medical or nursing care is also very important for this type of disease condition.
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
This is a lecture note for 5th semester MBBS students. Lecture notes on hepatology, liver disease, alcoholic liver disease, alcohol-related liver disease, portal hypertension, hepatic encephalopathy, and acute liver failure. Introduction to acute liver failure, causes, approach, and management of acute liver failure .
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. INTRODUCTION
ALF is a rare condition in which rapid
deterioration of liver function results in altered
mentation and coagulopathy in individuals
without known pre-existing liver disease.
ALF often affects young persons & carries a
high morbidity & mortality
ACUTE LIVER FAILURE (AASLD 2011)
3. DEFINITION
Evidence of coagulation abnormality , usually an
INR ≥ 1.5, & any degree of mental alteration
(encephalopathy) in a patient without pre-
existing cirrhosis & with an illness of < 26 weeks
duration.
Patients with wilson disease , vertically acquired
HBV, or AIH may be included in spite of the
possibility of cirrhosis if their disease has only
been recognized for < 26 weeks.
ACUTE LIVER FAILURE (AASLD 2011)
4. ACUTE LIVER FAILURE
A number of other terms have been used for
this condition , including fulminant hepatic
failure & fulminant hepatitis or necrosis.
“Acute liver failure” is a better overall term that
should encompass all durations upto 26 weeks.
ACUTE LIVER FAILURE (AASLD 2011)
5. CLASSIFICATION
ALF is classified in to three subcategories ,
depending upon the time lapsed b/w the
appearance of jaundice , to the development of
encephalopathy.
1) Hyper acute : < 7 days
2) Acute : 7 – 21days
3) Sub acute : > 21 days & < 26 weeks
ACUTE LIVER FAILURE (AASLD 2011)
6. PATHOPHYSIOLOGY
Loss of normal function of hepatic tissue which
occurs over a short period of time.
It results in the loss of the metabolic , secretory ,
& regulatory effects of the liver cells.
This results in the rapid accumulation of toxic
substances , which then manifests in the patient
as an altered sensorium , cerebral edema ,
hemodynamic abnormalities & even multiorgan
failure.
ACUTE LIVER FAILURE (AASLD 2011)
7. CAUSES OF ALF
Viral hepatitis Hep A, B, E, D, HSV, VZV, CMV
Drugs Dose-related : Acetaminophen
Idiosyncratic : antibiotics, anti TB, .
. anticonvulsants, NSAIDs
Toxin Mushroom poisoning, CCl4
Vascular Ischemic hepatitis, Budd-Chiari syndrome,
veno-occlusive disease
Metabolic Wilson disease
Pregnancy Acute fatty liver, Eclampsia, HELLP
syndrome
Misc Malignant infiltration, sepsis, AIH
Indeterminate
ACUTE LIVER FAILURE (AASLD 2011)
8. VIRAL HEPATITIS
Viral hepatitis may lead to ALF.
Hepatitis A & B account for most of these cases.
Hepatitis C rarely causes ALF.
Hepatitis D, as a co-infection or super infection
with HBV can lead to ALF.
Hepatitis E (often observed in pregnant women)
in an endemic area is an imp cause of ALF.
ACUTE LIVER FAILURE (AASLD 2011)
10. ACETAMINOPHEN
HEPATOTOXICITY
Acetaminophen is a dose related toxin, most
ingestion leading to ALF exceed 10gm/day
(150mg/kg).
However severe liver injury can occur rarely
when doses as low as 3-4 gm/day are taken.
Very high ALT levels are typically seen , serum
levels exceeding 3500 IU/L are highly correlated
with acetaminophen poisoning.
ACUTE LIVER FAILURE (AASLD 2011)
11. ACETAMINOPHEN
HPATOTOXICITY
Because acetaminophen is the leading cause of
ALF (at least in the US & Europe) & there is an
available antidote, acetaminophen levels should
be drawn in all patients presenting with ALF.
Specific indication that acetaminophen may be
the culprit include very high ALT & low bilirubin
levels, in the absence of apparent hypotension
& cardiovascular collapse.
ACUTE LIVER FAILURE (AASLD 2011)
12. MUSHROOM POISONING
There is no available blood test to confirm the
presence of these toxins, but this diagnosis
should be suspected in patients with a history of
severe GI symptoms (nausea, vomiting,
diarrhea, abdominal cramping), which occurs
within hours to a day of ingestion.
ACUTE LIVER FAILURE (AASLD 2011)
13. DRUG INDUCED LIVER INJURY
Drugs other than acetaminophen rarely cause
dose-related toxicity.
Most examples of idiosyncratic drug
hepatotoxicity occurs within the first 6 months
after drug initiation.
Classes of drugs commonly implicated include
antibiotics, NSAIDs & anticonvulsants.
ACUTE LIVER FAILURE (AASLD 2011)
14. DRUG INDUCED LIVER INJURY
Certain herbal preparations, weight loss agents
& other nutritional supplements have been
found to cause liver injury, so inquiry about such
substances should be included in a complete
medication history.
ACUTE LIVER FAILURE (AASLD 2011)
15. Uncommon cause of ALF.
Typically occurs in young patients,
accompanied by the abrupt onset of Coombs
negative hemolytic anemia with serum bilirubin
levels >20 mg/dl.
Kayser-Fleischer rings are present in about 50%
of patients
WILSON DISEASE
ACUTE LIVER FAILURE (AASLD 2011)
16. WILSON DISEASE
Serum ceruloplasmin is typically low, but may
be normal in upto 15 % of cases & is reduced in
῀ 50% of other forms of ALF.
High urinary & plasma copper levels as well as
hepatic copper measurement will confirm the
diagnosis.
Very low serum ALP & uric acid levels.
A high bilirubin (mg/dl) to ALP (IU/L) ratio ( >
2.0) is a rapid (indirect) indicator.
ACUTE LIVER FAILURE (AASLD 2011)
17. Acute hepatic vein thrombosis
Abdominal pain, ascites and striking
hepatomegaly are often present.
Diagnosis confirmed with hepatic imaging
studies (computed tomography, Doppler
ultrasonography, venography, magnetic
resonance venography) & testing to identify
hypercoagulable conditions (polycythemia,
malignancies).
BUDD CHIARI SYNDROME
ACUTE LIVER FAILURE (AASLD 2011)
18. ACUTE ISCHEMIC INJURY
Shock liver: cardiac arrest; significant
hypotension/hypovolemia; severe CHF
Drug induced hypotension/hypoperfusion: long
acting niacin; cocaine; methamphetamines
Documented hypotension not always found
Transaminases often > 1000-2000 mg/dL;
Simultaneous renal insufficiency and/or muscle
necrosis often found
ACUTE LIVER FAILURE (AASLD 2011)
19. AIH patients that develop ALF represent the
most severe form of the disease.
Auto-antibodies absent (up to 30% of cases)
Liver biopsy should be considered if
autoimmune hepatitis is suspected and
autoantibodies are negative.
AUTOIMMUNE HEPATITIS
ACUTE LIVER FAILURE (AASLD 2011)
20. Acute Fatty Liver of Pregnancy/HELLP (Hemolysis,
Elevated Liver Enzymes, Low Platelets) Syndrome.
A small no. of women near the end of pregnancy will
develop rapidly progressive hepatocyte failure associated
with increased fetal or maternal mortality.
A variety of presentation may be seen generally confined
to the last trimester.
Triad of jaundice, coagulopathy, and low platelets
Hypoglycemia and features of pre-eclampsia are
common.
ALF IN PREGNANCY
ACUTE LIVER FAILURE (AASLD 2011)
21. MALIGNANT INFILTRATION
Malignant infiltration of the liver may cause ALF.
Acute severe hepatic infiltration occurs with
breast Ca, small cell lung Ca, lymphoma,
melanoma & myeloma.
In patients with ALF who have a previous
cancer history or massive hepatomegaly,
consider underlying malignancy & obtain
imaging & liver biopsy to confirm or exclude the
diagnosis.
ACUTE LIVER FAILURE (AASLD 2011)
22. INDETERMINATE ETIOLOGY
If the etiological diagnosis remains elusive after
extensive initial evaluation , liver biopsy may be
appropiate to attempt to identify a specific
etiology that might influence treatment strategy.
Causes of cases believed to represent
indeterminate ALF , & subsequently recognized
include acetaminophen, AIH , & malignancies.
ACUTE LIVER FAILURE (AASLD 2011)
23. CLINICAL MANIFESTATIONS
Many of the initial symptoms in patients with
ALF are non-specific : (fatigue, malaise,
anorexia, nausea, vomiting, abdominal pain,
lethargy).
As the liver failure progress, patients who were
initially anicteric may develop jaundice, & those
with subtle mental status changes (e.g lethargy,
difficulty sleeping) may become confused or
eventually comatose.
ACUTE LIVER FAILURE (AASLD 2011)
28. HISTORY
Date of onset of jaundice & encephalopathy.
Alcohol abuse
Medication use (prescription & recreational)
Herbal or traditional medicine use
Family hx of liver disease (wilson disease)
Exposure to hepatic toxins (mushroom, organic
solvents)
ACUTE LIVER FAILURE (AASLD 2011)
29. HISTORY
Exposure to risk factors for viral hepatitis (travel,
transfusion, sexual contacts, occupation, body
piercing)
Evidence of complications (e.g renal failure,
seizures, bleeding, infections)
ACUTE LIVER FAILURE (AASLD 2011)
30. PHYSICAL EXAMINATION
Mental status examination & grading of HE.
Search for stigmata of CLD (usually absent)
Jaundice
RUQ tenderness
Hepatomegaly (viral hepatitis, malignant
infiltration, CHF, Budd Chiari syndrome)
ACUTE LIVER FAILURE (AASLD 2011)
31. PHYSICAL EXAMINATION
Rapid development of ascitis in ALF patient,
accompanied by abdominal pain suggest the
possibility of BC syndrome.
Clinical signs of elevated ICP (systemic
hypertension, bradycardia & irregular respiration
_cushing triad & other neurologic changes such
as pupillary dilatation or decerebrate posture)
ACUTE LIVER FAILURE (AASLD 2011)
32. INITIAL INVESTIGATIONS
Coagulation studies PT / INR
CBC Thrombocytopenia
LFTs Elevated levels of ALT, AST, ALP, Bilirubin
RBS May be low
Serum electrolytes Including HCO3, Ca, Mg, Phosphorus
RFTs Creatinine may be elevated
Blood group & screen
Pregnancy test
ABGs May reveal hypoxemia
Ammonia Elevated
Arterial lactate Often elevated
ACUTE LIVER FAILURE (AASLD 2011)
33. ETIOLOGY SPECIFIC
Viral hepatitis Anti-HAV IgM
HBsAg, anti-HBc IgM
Anti-HCV, HCV RNA
Hepatitis D virus IgM
Anti-HEV
HSV1 IgM, VZV
Wilson disease Ceruloplasmin, serum & urinary copper
Autoimmune hepatitis ANA, ASMA, Immunoglobulin levels
Budd Chiari syndrome Hepatic doppler USG, Abd CT or MRI
Drugs and toxins Acetaminophen level
Toxicology screen
Indeterminate Liver biopsy
ACUTE LIVER FAILURE (AASLD 2011)
34. MANAGEMENT
Therapy of ALF consist of general supportive
measures (complications), specific therapies for
some of the etiologies, liver transplantation &
other methods of temporary liver support.
ACUTE LIVER FAILURE (AASLD 2011)
40. LIVER TRANSPLANTATION
It remains the only effective therapy for ALF
patients who fail to recover spontaneously.
king`s College criteria is used to select the
patient that should be referred to a transplant
center for transplantation.
ACUTE LIVER FAILURE (AASLD 2011)
42. LIVER SUPPORT SYSTEMS
Are support devices which help in resting the
liver to provide it sometime to recover.
There are two kinds of devices, sorbent based
artificial systems & cell based bio-artificial
systems.
There is no good evidence showing a decrease
in mortality with their use in ALF.
They are not currently recommended outside of
clinical trials.
ACUTE LIVER FAILURE (AASLD 2011)
43. PROGNOSIS
Cause of ALF: most significant predictor of
outcome
Acetaminophen, Hepatitis A, shock liver,
pregnancy related with > 50% OLT free
survival
All others < 20% OLT free survival
Degree of encephalopathy: Grade I-II with 65-
70% spontaneous recovery; Grade III-IV < 20%
Age: > 40 yr or < 10 yr have worse outcome
ACUTE LIVER FAILURE (AASLD 2011)
44. SUMMARY
Patients with ALF should be hospitalized &
monitored frequently, preferably in an ICU.
The precise etiology of ALF should be sought to
guide further management decisions.
NAC may be used in the setting of non-
acetaminophen ALF including, e.g DILI &
hepatitis B.
ACUTE LIVER FAILURE (AASLD 2011)
45. SUMMARY
The development of cerebral edema is the
major cause of morbidity & mortality in patients
with ALF.
ACUTE LIVER FAILURE (AASLD 2011)