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Fulminant Hepatitis
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Fulminant Hepatitis
, Acute Hepatic Failure, Acute Liver Failure
See Also
Acute Hepatitis
Definitions
Fulminant Hepatitis
Rapid onset and progression within weeks to liver necrosis with secondary
Hepatic Encephalopathy
and
Coagulopathy
Epidemiology
Incidence
: 2000 cases per year in the United States
Pathophysiology
Massive hepatic necrosis over the course of days to weeks
Results in rapid progression from
Jaundice
to encephalopathy and
Coagulopathy
Multiorgan failure including
Acute Renal Failure
follows
Types
Timing based on pregression from
Jaundice
onset to encephalopathy
Acute Liver Failure within 1 week
Hyperacute liver failure
Acute Liver Failure within 1-4 weeks
Acute Liver Failure
Acute Liver Failure over >5-8 weeks
Subacute liver failure
Causes
Infectious Disease
Viral Hepatitis
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Bacterial Infection
Rickettsia
l infection
Parasitic Infection
Toxic Hepatitis
Hepatotoxin
exposure or other drug-induced cause
Examples:
Acetaminophen Overdose
, Amanita muscaria ingestion
Ischemia or shock
Budd-Chiari Syndrome
Idiopathic Chronic Active Hepatitis
Wilson's Disease
(Acute)
Microvesicular
Steatosis
(Fat) Syndromes
Nonalcoholic Fatty Liver
Acute Fatty Liver of Pregnancy
Reye's Syndrome
Symptoms
Vomiting
Upper
Abdominal Pain
Anorexia
Jaundice
Signs
Neurologic changes (
Hepatic Encephalopathy
)
Altered Level of Consciousness
(
Delirium
, coma)
Decerebrate rigidity (with severe cerebral edema)
Personality change
Jaundice
Coagulopathy
Bleeding (e.g.
Gastrointestinal Bleeding
)
Acute Renal Failure
(
Hepatorenal Syndrome
)
Hypoglycemia
Acute Pancreatitis
Cardiopulmonary failure
Ascites
(due to
Portal Hypertension
)
Labs
See
Acute Hepatitis
Imaging
See
Acute Hepatitis
Management
Targeted therapy
Delivery for pregnancy related
Acute Liver Disease
(especially
Acute Fatty Liver of Pregnancy
)
Withdraw all known
Hepatotoxin
s
Treat known
Hepatotoxin
exposures
Consult with poison control and hepatology
Consider empiric
N-Acetylcysteine
in possible acute
Toxic Hepatitis
Effective beyond
Acetaminophen Overdose
or Amanita muscaria ingestion
Duration typically longer (>24 hours) than for
Acetaminophen Overdose
(per poison control)
Supportive care
ABC Management
Endotracheal Intubation
often required
Fluid and
Electrolyte
s
Volume expansion with crystalloid initially, but avoid
Fluid Overload
Consider
Albumin 25%
at 50-100 ml aliquot or
Albumin 5%
at 250 ml aliquot
Liver
failure is associated with hypoalbuminemia
Correct acid-base status and
Electrolyte
abnormalities
Monitor
Serum Glucose
Correct
Hypoglycemia
with IV D10 or D20 prn
Hemorrhagic Shock
Consider FFP or
PCC4
for
Coagulopathy
and severe active bleeding
INR is not an accurate measure of bleeding risk in the absence of
Warfarin
Vasopressor
s
Consider
Vasopressin
as a first-line
Vasopressor
in liver failure
Prevent
GI Bleed
H2 Blocker
s to maintain gastric pH >3.5
Monitor for infection
Complicated by
Bacteria
l or fungal infection in 80% of cases
Infection is often occult with non-specific changes in status (e.g. worsening encephalopathy)
Routinely monitor urine,
Chest XRay
and other markers of infection
Consider prophylactic antibiotics (e.g.
Ceftriaxone
)
Hepatic Encephalopathy
Encephalopathy may be more severe in Acute Liver Failure than in longstanding
Cirrhosis
Obtain
Head CT
and
Ocular Ultrasound
for
Optic Nerve Sheath Diameter
Consider
Endotracheal Intubation
Control systemic
Hypertension
Consider evaluation of
Intracranial Pressure
(questionable efficacy)
Lower
Intracranial Pressure
with Mannitol IV prn (while replacing urine losses)
Transfer to center capable of performing liver transplant (if potential candidate)
Liver
Transplant Indications
Grade 3-4 Encephalopathy
Adverse prognostic indicators as above
Prognosis
Factors associated with poor outcomes
Advanced age
Halothane exposure
Hepatitis C
Coma
(80% Mortality)
Rapid decrease in liver span
Respiratory Failure
Marked
ProTime
prolongation
Factor V Level <20%
References
Swaminathan and Weingart in Herbert (2020) EM:Rap 20(10):1-2
Swencki (2015) Crit Dec Emerg Med 29(11):2-10
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