Post on 02-Nov-2014
description
Fulminant hepatic failure (FHF)
DEFINITION
rapid development of severe acute liver injury
with impaired function and encephalopathy in previously normal liver or well compensated liver disease
Fulminant hepatic failure (FHF)
encephalopathy within 8 wks previous healthy liver
encephalopathy within 2 wks of developing jaundice with previous underlying liver dysfunction
แบ่�งเป็�น 2 ระยะ
FHF > 8 wks - 6 months
Subfulminant hepatic failure (sub FHF)
cerebral edema is common in FHF and rare in sub FHF
renal failure and portal hypertension are more frequently with sub FHF
FHF VS sub FHF
Reverse altered mental and neuromotor function
Associated acute or chronic liver disease
Hepatic Encephalopathy
Pathophysiology
causes
cause พบร้�อยละacetaminophen over dose in determineidiosyncratic drug reaction viral hepatitis A, B
39171312
The Acute liver Failure Study Group
พ.ศ.2541- 2544
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
causes
Toxins
causes
Vascular
portal vein thrombosisBudd-Chiari syndrome (hepatic vein
thrombosis)veno-occlusive diseaseischemic hepatitis
causes
Metabolic
Wilson's diseaseacute fatty liver of pregnancyReye's syndrome
causes
Miscellaneous
malignant infiltration of the liver,heat strokesepsisautoimmune hepatitis.
causes
Acute liver failurenonspecific symptomsmalaise nauseaJaundiceEcchymosesEtc…..
Sign and symptom
Hepatic encephalopathyAges 10–60 yearsHandwriting and hand coordination
deteriorate in stages 1 and 2Asterixis prominent in stage 2Reflexes symmetrically hyperactive in stage 3Mental and neurologic signs change rapidly
(over 6–12 hours)
Sign and symptom
Age >60Signs of underlying liver disease diminish
(25%)Confusion more prominentPrecipitating GI hemorrhage or infection less
often identifiedRemains in stage 1 or 2 for many daysProgression slower
Sign and symptom
Age <10Signs of underlying liver disease prominent;
usually FHF or extremely advanced cirrhosisProgression through the stages very rapid,
often 6–12 hoursWilson disease can imitate HE
Sign and symptom
Hepatic encephalopathy
Sign and symptom
http://emedicine.medscape.com/article/177354-clinical#showall
Hepatic encephalopathyCerebral edemaSepsisRenal failureCirculatory dysfunctionCoagulopathyGastrointestinal bleedingPulmonary complicationMetabolic disturbance เช่�น metabolic acidosis,
hypoglycemia, hypophosphatemia
FHF complication
Diagnosis
The clinical setting and findings diagnosis in 80% of the cases.The treatment response often confirms the diagnosis
HematologyCBC, coagulation
Biochemistry, blood gasblood glucose, BUN, creatinine, electrolyte, LFT
Blood gasVirological markers
Hepatitis profile (A, B, C, delta)Microbiology
HemocultureSputum / urine culture
Electroencephalogram (EEG)
Lab investigation
Specific treatment Liver transplant Stage 3 and 4
Complication treatmentHepatic encephalopathyCerebral edemaSepsisRenal failureCirculatory dysfunctionCoagulopathyGastrointestinal bleedingPulmonary complicationMetabolic disturbance
Treatment
Hepatic encephalopathy (HE) ammonia within the gut lumenConcept ammonia precipitating factors IGSCALP
Restrict Protein diet = 40-70 g/daynon-absorbable disaccharides = lactuloseantibiotic = rifaximin, neomycin,
metronidazole, vancomycin
Complication treatment
First Line50% 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
goodMetronidazole and vancomycin are alternative antibiotics.Antacids as needed
Second LineFlumazenil (benzodiazepine antagonist)
Cerebral edemaastrocyte edemaIICP and brainstem herniation, most common
causes of death classic signs IICP include Cushing's triad and Neurologic manifestations hypertonic,
hyperreflexia, and altered pupillary responses
Complication treatment
Treatment cerebral edemaControl ICP < 20 mmHg and CPP > 50
mmHgEnv. with minimal sensory stimulationelevate head position prevent overhydrationif ICP > 20 mmHg Hyperventilation
PCO2 < 25 mmHg if no response use hyperosmotic agents
manitol 0.5 - 1 g/kgIf no response use pentobarbitone 3-5
mg/kg IV
Complication treatment
1. Liver transplant 2. Liver recovery
2.1 Grade ของ encephalopathy(50)Grade I-II recovery 65-70Grade III 40-50Grade IV < 20
2.2 Age ถ้�าอาย�น�อยกว่�า 10 ป็� หร�อมากกว่�า 40 ป็�โอกาสฟื้�� นคื�นก!น�อยลง
2.3 cause FHF เช่�น acetaminophen >idiosyncratic drug reactions > Wilson’s disease
prognosis
รศ.พญ. ว่$ฒนา ส�ข&ไพศาลเจร)ญ. Acute liver failure. ภาคืว่)ช่าอาย�รศาสตร, คืณะแพทยศาสตร, มหาว่)ทยาล$ย
ขอนแก�นhttp://
emedicine.medscape.com/article/186101-overview#showall
http://www.sciencedirect.com/science/article/pii/S1357272502003965
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
I = infectionG = GI bleedingS = sedationC = constipationA = alkalosisL = low KP = protein high
IGSCALP