General: Severe liver disease in a patient without preexisting cirrhosis with encephalopathy and impaired synthetic functions.

Etiology: Most common cause is Acetaminophen toxicity; viral hepatitis and drug reactions are also very common.

Work Up:

-CBC, Chem 7 → look for thrombocytopenia and need Cr for MELD score

-Coagulation Studies → to assess synthetic function of liver.

-LFT’s, ALK-P, bilirubin and Albumin.

-Ammonia

-Tylenol, Viral Hepatitis

Management:

-Mostly supportive; treat the underlying etiology.

-Early consultation to transplant center v. hepatology v. GI. 

-D5NS preferred as these patients are prone to hypoglycemia.

-Lactulose and Rifaximin for Hepatic Encephalopathy.

-Consider Phenytoin over benzos for seizure to prevent benzo overdose secondary to depressed hepatic clearance.

-Monitor for coagulopathy and thrombocytopenia.

-Paracentesis and ceftriaxone if concerned for Spontaneous Bacterial Peritonitis (SBP).

-Major cause of death in Acute Liver Failure is cerebral edema and intracranial hypertension.

References:

Bailey, C, Hern HG. Hepatic Failure: An Evidence-Based Approach In The Emergency Department. Emergency Medicine Practice. Vol. 12, No. 4, 2014.

Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204