ACUTE LIVER FAILURE - PowerPoint PPT Presentation

Loading...

PPT – ACUTE LIVER FAILURE PowerPoint presentation | free to download - id: 82d939-ZjgyY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

ACUTE LIVER FAILURE

Description:

ACUTE LIVER FAILURE Milton G. Mutchnick, M.D. Professor of Medicine Chief, Division of Gastroenterology Wayne State University School of Medicine Acute Liver Failure ... – PowerPoint PPT presentation

Number of Views:102
Avg rating:3.0/5.0
Slides: 47
Provided by: EmilyS158
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: ACUTE LIVER FAILURE


1
ACUTE LIVER FAILURE
Milton G. Mutchnick, M.D. Professor of
Medicine Chief, Division of Gastroenterology Wayne
State University School of Medicine
2
Acute Liver Failure
Rapid deterioration of liver function resulting
in altered mentation and coagulopathy in a
patient without preexisting cirrhosis and with an
illness of less than 26 weeks duration.
3
Acute Liver Failure.AKA
  • Fulminant hepatic failure
  • Fulminant hepatitis
  • Subfulminant liver failure
  • Subacute hepatic necrosis
  • Subacute liver failure
  • Hyperacute liver failure

4
Index of Suspicion for ALF
  • Clinical signs of moderate to severe hepatitis
  • Laboratory findings including an increase in the
    prothrombin time of 4-6sec.(INR 1.5).
  • Altered sensorium
  • INR 1.5 Altered Mental Status ALF

5
  • Suspect ALF?..........Admit to ICU

6
Etiology of ALF
  • Acute viral hepatitis (A - E)
  • Mushroom poisoning
  • Acetaminophen
  • Acute fatty liver of pregnancy
  • Chemical agents

7
  • Drug-induced hepatitis
  • Budd-Chiari Syndrome
  • VOD of liver
  • Wilsons disease
  • AIH

8
ALF Etiologies
  • Viral
  • Drug
  • Poisoning
  • Ischemia
  • VOD
  • Malignant Infiltrate
  • Wilsons Disease
  • Microvesicular steatosis
  • AIH
  • Hyperthermia
  • OLT
  • Partial hepatectomy

9
Etiology of ALF in 342 Cases (University
Hospital, London UK)
Drugs-Overdose Other Acetaminophen
250 Wilsons 3 Ecstasy
2 Fatty liver of pregnancy 7 Lymphoma/ Vir
al Hepatitis malignant infiltrate
7 HAV 8 Sepsis 2 HBV
8 Budd-Chiari 5 Non A-E
28 Ischemia 9 Miscellaneous
6 Idiosyncratic Drug Reactions Lamotrigine,
cyproterone, NSAID, chloroguine, rifampin/
INH halothane, flucloxacillin
10
U.S. ALF STUDY GROUP 2003 (308 Patients, 73
Women)
11
Viral
  • Acute Hepatitis A-E
  • Reactivation of HBV
  • Chemotherapy
  • Immunosuppresion
  • Herpes simplex
  • Varicella-Zoster
  • EBV

12
Acute HAV and ALF
  • ALF uncommon
  • Frequency 0.01 - 0.1 in
  • jaundiced patients
  • ALF occurs early
  • Survival (transplant- free) 75
  • Age related survival

13
Acute HBV and ALF
  • HBV alone or with HDV co-infection
  • (rare)
  • Transplant-free survival is 23
  • Overall survival 77 because of
  • transplantation

14
HBV Markers in ALF
IgM Anti HBc 100 HBsAg 90 HBV DNA
(Abbott) 10 Absence of HBsAg favors better
prognosis (47 v 17). Higher frequency ALF
with mutant HBV form
15
Drug Induced ALF
  • Many drugs implicated
  • Acetaminophen
  • Halothone and derivatives
  • INH/ Rifampin
  • Tricyclics/ MAO inhibitors
  • Phenytoin/ NSAID
  • Increased risk acetaminophen (as little as
  • 2gms) ETOH median dose 13 gm
  • Increased risk if drug continued after
  • jaundice appears

16
Poisoning and ALF
  • Amanita mushrooms (amanatoxins)
  • - LD 50 gms (3 mushrooms)
  • - Toxins not destroyed by cooking
  • - Rapid onset of HE in 4-8 days
  • following severe emesis and diarrhea
  • Solvents - chlorinated hydrocarbons
  • Herbal remedies
  • Yellow phosphorus

17
Ischemic Hepatitis and ALF
  • Liver cell necrosis - massive
  • scale
  • Cardiac tamponade
  • Acute heart failure
  • Pulmonary embolus
  • Hepatic artery thrombosis

18
Obstruction of Hepatic Veins and ALF
  • Budd-Chiari syndrome and thrombosis of hepatic
    veins
  • VOD - Post BMT Chemotherapy, Irradiation

19
Massive Malignant Infiltration of the Liver
  • Attributed to ischemic
  • changes
  • Leukemia, lymphoma
  • Malignant histiocytosis
  • Metastatic Replacement

20
Other Etiologic Causes of ALF
  • Wilsons Disease
  • can be presenting feature
  • usually in patients lt20 yrs
  • can occur if patient discontinued
  • D-penicillamine for a few years

21
Other Etiologies (2)
  • Microvesicular steatosis
  • Acute fatty liver of pregnancy
  • Reyes syndrome
  • Drug Induced - Valproic acid
  • AIH
  • May appear as an acute hepatitis
  • on initial presentation
  • More common if anti-LKMI antibody present
  • ASMA usually not present

22
Other Etiologies (3)
  • Hyperthermia (Heat stroke)
  • Direct thermal injury
  • Hepatic ischemia due to
  • -DIC
  • -Perfusion defect
  • OLT
  • Poor presentation of donor liver
  • Acute graft rejection
  • Thrombosis - hepatic artery, hepatic
  • vein, portal vein
  • Partial hepatectomy
  • Removal of 80 or more of healthy liver
    Removal of 50 or less in hepatic dysfunction

23
Evaluation Diagnosis of Impending ALF
History! History! History! Sexual
contacts IDU Risk
Factors Pregnancy Mushrooms
Medications Travel Toxic exposures
24
HISTORY
  • Family members with liver disease?
  • Recent cold sores
  • Onset of jaundice
  • Work environment- toxic agents
  • Hobbies
  • Herbal products/dietary supplements

25
Physical Exam
Determine presence or absence of pre-existing
liver disease Hepatic tenderness Hepatic
decompensation
26
Laboratory Tests (1)
  • Drug screening
  • ALT, AST, Alk Phos, Glu,
  • Bilirubin
  • Lytes, Albumin, Mg, Phos.,
  • CBC with differential
  • Coags PT, PTT
  • Anti HAV IgM
  • Anti HBc IgM/ Anti HBsAg/
  • Anti-HCV

27
Laboratory
Tests (2)
  • If under 35 years of age
  • Ceruloplasmin
  • Serum urine copper
  • Arterial blood gas
  • Arterial lactate
  • Pregnancy test
  • Autoimmune markers ANA, ASMA, Ig levels
  • HIV status
  • Amylase lipase

28
Liver Biopsy
Reserved for diagnostic dilemma - AIH,
HS (Transjugular approach)
29
Diagnosis of ALF
  • Hallmarks - occurs simultaneously or in
  • succession
  • Altered mentation
  • Clinical
  • EEG
  • Arterial Ammonia
  • Coagulopathy
  • PT 4 sec prolonged (INR 1.5)
  • Arterial pHlt7.3 if acetaminophen ingested
    (cause for immediate transfer for OLT)

30
Management of ALF (1)
  • Directed towards prevention of complications
  • ICU setting
  • Central line(s)-10 dextrose
  • Pulmonary artery pressure and CO
  • Inform Transplant Service and transfer with
  • onset of HE
  • Monitor VS and urinary output (Foley)
  • strict IO
  • Laboratory Testing every 4-6hr
  • electrolytes, BUN, creatinine, CBC,
    platelets,
  • PT, PTT, ALT, AST, T. bilirubin, Alk Phos,
    Albumin

31
Management (2)
  • Maintain gastric pH above 5
  • - protonix IV
  • Preparation for endotracheal intubation
  • Prepare to initiate monitoring intracranial
  • pressure
  • Enteral feeding tubes for grade 3 or 4 coma

32
Cerebral Edema Cerebral Perfusion Pressure
Mean Arterial Pressure ICP Cerebral
Perfusion Pressure (CPP) Ideal
ICPlt20-25mm Hg Ideal CPPgt50-60mm Hg Imazaki, et
al When CPPlt40 for 2 hrs. 0 of 7 patients
recovered When CPPgt50 6 of 8 patients
recovered Improved ICP first sign of spontaneous
recovery
33
Management (3)
Cerebral Edema Intracranial Hypertension
(Most serious complications of ALF) Clinical
signs of elevated ICP (Intracranial
Pressure) -sluggish pupillary response -increase
d limb-muscle tone -none Monitoring
ICP -usually reserved for grade 3 or 4
coma -awaiting OLT
34
Management (4)
Cerebral Edema - General Measures -quiet
environment -elevate head 10-20 -avoid
sedation (use restraints) -avoid
Valsalva-like maneuvers -mental status
assessments q1-2h -mannitol if signs of
impending uncal herniation
(0.5mg/kg, lolus q4-8h) when
ICPlt30-40mm -assisted ventilation (in all grade
3 and 4)
35
Multiple Organ Failure
Hepatic damage increased risk of
infection Failure of
clearance Endotoxemia Gut
leak MOF Activation of macrophages Tissu
e Circulating Release of Hypoxia changes cyt
okines TNF, IL-1, IL-6 Williams, Sem Liver
Dis, Vol 16, No.4, 1996
36
Management (5)
  • Hemodynamic Complications include
  • Hypotension, tachycardia, vascular volume
    decrease with capillary leak and vasodilation
  • Volume expansion (central line)
  • FFP or 4.5 albumin, 10 dextrose
  • Maintain pulmonary capillary wedge
  • pressure 12mm-14mm Hg
  • Minimize salt solutions (ascites,
  • interstitial accumulation)
  • Inotropic/pressor support(epi, norepi, dopamine),
  • but not vasopressin.

37
Management (6)
  • Coagulopathy/Bleeding Diathesis
  • FFP or platelets given in presence of bleeding
  • Conventional treatment of GI bleeding
  • DIC thrombocytopenia
  • Metabolic Complications
  • Prevent hypoglycemia
  • Phosphate and magnesium levels
  • monitored - replace early
  • Enteral feeding, 60gm protein/24 hrs
  • No role for high branched-chain AA
  • Monitor for lactic acidosis secondary to
  • tissue hypoxia, sepsis

38
Role of Cardiac Index
  • (CI cardiac output/body surface area)
  • ALF associated with high CI
  • Presence of low CI (lt4.5L/min)
  • is bad prognostic sign
  • Look for -
  • blood loss, pneumothorax
  • lactic acidosis, cardiac tamponade

39
Management (7)
Renal Failure - In 42 to 82 of ALF poor
prognostic sign - Rising creatinine and
oliguria - Metabolites of acetaminophen are
nephrotoxic leading to acute renal failure
similar to ATN and loss of phosphate -HRS
40
Additional Complications
  • ARDS
  • Sepsis
  • - Severe complement deficiency
  • - Decreased PMN motility
  • - Decreased Kupffer cell function
  • and removal of endotoxins
  • - Increased levels of TNF and IL-6

41
Prognostic Factors
  • Dependent on Etiology
  • Younger patients do better (lt40 and gt10)
  • Presence of cerebral edema
  • Delay between jaundice and HE of more
  • than 3 weeks - poorer prognosis
  • MOF - poor prognosis

42
Current Treatment
Transplantation
43
Temporary Measures
  • Hemodialysis - no proven benefit on survival
  • Charcoal hemoperfusion - no proven benefit
  • Resins (Cation or anion - exchange) - not proven
  • Extracoporeal liver perfusions - may be bridge
  • to OLT
  • Hepatocyte transplants (peritoneum) - uncertain
  • Capillary hollow-fiber system - unproven,
  • ?bridge

44
OUTCOME RESULTS U.S. ALF STUDY
GROUP
45
(No Transcript)
46
Approach to Suspected ALF
  • Etiology and Pathogenesis
  • Evaluation and Diagnosis
  • Complications
  • Management
  • Prognosis
  • Current and future treatment
  • approaches
About PowerShow.com