Key points in Critical Care Medicine
Pathophysiology, causes, and management of acute hepatic failure
“Adapted from Oxford Textbook of Critical Care”
- Acute liver failure (ALF) is a rare, life-threatening clinical syndrome occurring in a person with no prior history of liver disease.
- Acute liver failure (ALF) occurs in patients with acute hepatic necrosis resulting in hepatic encephalopathy, jaundice, and coagulopathy.
- Acute liver failure is a multisystem disorder.
- Viral hepatitis is the most common cause of ALF worldwide, with drug-induced liver failure the most common in the developed world.
- ALF is a multi-system disorder resulting in encephalopathy, coagulopathy, systemic inflammatory response syndrome, and multi-organ failure.
- Patients can be prothrombotic or have balanced coagulation disorders.
- Several classifications exist incorporating time to encephalopathy from the onset of jaundice. O’Grady’s classification is the most widely used.
- The management is initially supportive. Intravenous N-acetylcysteine is recommended for all patients.
- Elective intubation is recommended for all patients who develop Grade III hepatic encephalopathy.
- Liver transplantation is an appropriate and viable treatment for ALF. Early and safe transfer to a transplant centre for transplant assessment is advised.
Classification Time of onset jaundice to encephalopathy
Hyper acute 0-1 weeks
Acute 1-4 weeks
Subacute 4-26 weeks
Causes
- Paracetamol, ischemia, recreational drugs, toxins (amanita)
- Hepatitis B,A, and E
- Non-paracetamol drug-induced liver injury, seronegative
- Hepatitis.