Acute liver failure is defined as severe liver injury with impaired function and encephalopathy in a previously healthy liver or one with underlying disease. Common causes include acetaminophen overdose, idiosyncratic drug reactions, and viral hepatitis A and B. Prognosis depends on the grade of encephalopathy, with higher grades having lower recovery rates. Treatment involves treating complications like cerebral edema, infections, and managing precipitating factors of hepatic encephalopathy. Liver transplantation may be considered for patients with grade 3 or 4 encephalopathy.

2. DEFINITION

3.  rapid development of severe acute liver injury
with impaired function and encephalopathy
in previously normal liver or well compensated
liver disease

4.  encephalopathy within 8 wks previous
healthy liver
 encephalopathy within 2 wks of developing
jaundice with previous underlying liver
dysfunction

5.  FHF > 8 wks - 6 months

6.  cerebral edema is common in FHF and rare
in sub FHF
 renal failure and portal hypertension are
more frequently with sub FHF

7.  Reverse altered mental and neuromotor function
 Associated acute or chronic liver disease

11. cause
acetaminophen over dose 39
in determine 17
idiosyncratic drug reaction 13
viral hepatitis A, B 12
-

12. Hepatitis viruses
 hepatitis A most common acute viral hepatitis but
rare for acute infection to progress to ALF
 Hepatitis B most common viral cause ALF

13. Toxins

14. Vascular
 portal vein thrombosis
 Budd-Chiari syndrome (hepatic vein thrombosis)
 veno-occlusive disease
 ischemic hepatitis

15. Metabolic
 Wilson's disease
 acute fatty liver of pregnancy
 Reye's syndrome

16. Miscellaneous
 malignant infiltration of the liver,
 heat stroke
 sepsis
 autoimmune hepatitis.

17. Acute liver failure
 nonspecific symptoms
 malaise
 nausea
 Jaundice
 Ecchymoses
 Etc…..

18. Hepatic encephalopathy
Ages 10–60 years
 Handwriting and hand coordination deteriorate in
stages 1 and 2
 Asterixis prominent in stage 2
 Reflexes symmetrically hyperactive in stage 3
 Mental and neurologic signs change rapidly (over 6–12
hours)

19. Age >60
 Signs of underlying liver disease diminish (25%)
 Confusion more prominent
 Precipitating GI hemorrhage or infection less often
identified
 Remains in stage 1 or 2 for many days
 Progression slower

20. Age <10
 Signs of underlying liver disease prominent; usually
FHF or extremely advanced cirrhosis
 Progression through the stages very rapid, often 6–12
hours
 Wilson disease can imitate HE

21. Hepatic encephalopathy
http://emedicine.medscape.com/article/177354-clinical#showall

22.  Hepatic encephalopathy
 Cerebral edema
 Sepsis
 Renal failure
 Circulatory dysfunction
 Coagulopathy
 Gastrointestinal bleeding
 Pulmonary complication
 Metabolic disturbance metabolic acidosis,
hypoglycemia, hypophosphatemia

23. The clinical setting and findings diagnosis in 80% of
the cases.
The treatment response often confirms the diagnosis

24.  Hematology
 CBC, coagulation
 Biochemistry, blood gas
 blood glucose, BUN, creatinine, electrolyte, LFT
 Blood gas
 Virological markers
 Hepatitis profile (A, B, C, delta)
 Microbiology
 Hemoculture
 Sputum / urine culture
 Electroencephalogram (EEG)

25.  Specific treatment Liver transplant Stage 3 and 4
 Complication treatment
 Hepatic encephalopathy
 Cerebral edema
 Sepsis
 Renal failure
 Circulatory dysfunction
 Coagulopathy
 Gastrointestinal bleeding
 Pulmonary complication
 Metabolic disturbance

26. Hepatic encephalopathy (HE)
 ammonia within the gut lumen
 Concept ammonia
precipitating factors IGSCALP
 Restrict Protein diet = 40-70 g/day
 non-absorbable disaccharides = lactulose
 antibiotic = rifaximin, neomycin, metronidazole,
vancomycin

27. First Line
 50% Lactulose syrup 30–60 mL PO 4 times daily when ≥3
bowel movements occur daily.
 Lactulose enema 300 mL plus 700 mL tap water
 If worsening or no improvement in 2 days, add antibiotics:
 Rifaximin: 400 mg 3 times a day
 Neomycin: 1–2 g per day divided q6–8h, if renal status is
good
 Metronidazole and vancomycin are alternative antibiotics.
 Antacids as needed
Second Line
 Flumazenil (benzodiazepine antagonist)

28. Cerebral edema
 astrocyte edema
 IICP and brainstem herniation, most common causes
of death
 classic signs IICP include Cushing's triad and
 Neurologic manifestations hypertonic, hyperreflexia,
and altered pupillary responses

29. Treatment cerebral edema
Control ICP < mmHg and CPP > mmHg
 Env. with minimal sensory stimulation
 elevate head position
 prevent overhydration
 if ICP > mmHg Hyperventilation
PCO2 < mmHg if no response use
hyperosmotic agents
 manitol 0.5 - 1 g/kg
 If no response use pentobarbitone 3-5 mg/kg IV

30. 1. Liver transplant
Liver recovery
2.1 Grade encephalopathy(50)
Grade I-II recovery 65-70
Grade III 40-50
Grade IV < 20
Age
cause FHF acetaminophen >
idiosyncratic drug reactions > Wilson’s disease

31.  Acute liver failure.
 http://emedicine.medscape.com/article/186101-
overview#showall
 http://www.sciencedirect.com/science/article/pii/S135
7272502003965
 Eric Goldberg, Sanjiv Chopra. Acute liver failure:
Definition and etiology. Uptodate . Mar 2010
 Eric Goldberg, Sanjiv Chopra. Acute liver failure:
Prognosis and management. Dec 2010

32.  I = infection
 G = GI bleeding
 S = sedation
 C = constipation
 A = alkalosis
 L = low K
 P = protein high