Liver Evaluation

A/ P section should include an analysis of the following four topics:

• Synthetic Function
• INR (INR >1.5 with encephalopathy or >2 without encephalopathy = ALF)
  
• Ammonia
  
• Hepatocellular Injury
• ALT
• AST
  
• Cholestatis
• Total Bili
• Direct Bili
• GGT
  
• Structure / Anatomy
• Ultrasound
• elastography
• echotexture
  
• Doppler Flow
• r/o Venous Occlusice Disease (VOD)
  
• MRCP
• Liver Biopsy

Etiologic investigation

• PTT / INR
• Chemistries
• Na, K, Cl, Bibarb, Ca, Mg, P, Glucose
• AST, ALT, Alk Phos, GGT, T bili, Albumin, Creatinine, BUN
• ABG
• Arterial Lactate
• CBC
• Blood Type and Screen
• Acetaminophen Level
• Toxicology Screen
• Viral Hepatitis Serologies
• anti-HAV IgM
• HBsAg
• anti-HBc IgM
• anti-HEV**
• anti-HCV
• HCV RNA
• HSV1
• IgM
• VZV
• Additional Viruses as indicated
• HIV1, HIV2, etc
• Ceruloplasmin level if less then 40yo w/o another obvious explaination
• consider uric acid level as well
  
• Pregnancy Test (females)
• Ammonia (arterial if possible, requires specific collection and handling)
• Autoimmune Markers
• ANA
• ASMA (anti-smooth muscle antibody)
• Ig Levels
• Amylase and Lipase

• most often done via the transjugular route because of coagulopathy
• Indicated for suspected:
• autoimmune hepatitis
• Liver Mets
• Lymphoma
• Herpes Simplex Hepatitis

• May reveal cancer or budd chiari
• Nodular contour should not be interpreted as cirrhosis in this setting

Initial Management

• Patients with ALF should be hospitalized and monitored frequently, preferably in an ICU
• Early consultation with Liver Tranplant center with plans to transfer care as soon as possible
• Etiology should be determined to guide further management decisions

Etiologies and specific therapies

• Acetaminophen Hepatotoxicity
• known or suspected acetaminophen overdose within 4hrs of presentation
• give activated charcoal just prior to starting N-acetylcysteine (NAC) dosing
• Begin NAC promptly in all patients where any of the following indicate impending or evolving liver injury
• quantity of acetaminphen ingested
• serum drug level
• rising aminotransferases
  
• NAC may be used in cases of acute liver injury where acetaminophen ingestion is possible or when knowledge of circumstances surrounding admission is inadequate but aminotransferases suggest acetaminophen poisoning
• Mushroom Poisoning
• In ALF patients with known or suspected mushroom poisoning, consider administration of Penicillin G and N-acetylcysteine (NAC)
• Patients with ALF secondary to mushroom poisoning should be listed for transplantation as this procedure is often the only lifesaving option
• Drug Induced Liver Injury (DILI)
• Get complete medication history from the last year (Rx and non-Rx drugs, herbs, dietary supplements)
  
• onset of ingestion
• amount
• timing
• last dose
• Determine ingredients of non-Rx meds when possible
• In the setting of ALF due to possible drug hepatotoxicity, discontinue all but essential medications
• NAC may be beneficial for ALF due to DILI
• Viral Hepatitis
• Viral hepatitis A and E related ALF must be treated with supportive care as no virus specific treatment has proven to be effective
• Nucleoside/Nucleotide analogues should be considered for Hepatitis B-associated ALF and for prevention of post-transplant recurrence
• Patient with known or suspected herpes virus or vericella zoster as the cause of ALF should be treated with acyclovir (5-10mg/kg IV every 8hrs) and may be considered for transplantation
• Wilson Disease
• Exclude wilson disease with
• Ceruloplasmin
• serum and urinary copper levels
• Slit lamp exam for Keyser-Fleisher rings
• Hepatic copper levels if Liver Bx performed
• Total Bilirubin / Alk Phos ratio
• If Wilson disease is likely, patient needs prompt consideration for Liver Transplantation
• Autoimmune hepatitis
• Liver Bx is recommended if autoimmune hepatitis is suspected as the cause of acute liver failure and autoantibodies are negative
• Patients with coagulopathy and mild hepatic encephalopathy due to autoimmune hepatitis may be considered for corticosteroid treatment (prednisone 40-60 mg/day)
• Patients with autoimmune hepatitis should be considered for transplantation even while corticosteroids are being administered
• Acute Fatty Liver of Pregnancy /HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome
• Expedisious delivery of  the infant
• If ALF does not quickly resolve after delivery, consider transplantation
• Acute Ischemic Injury "Shock Liver"
  
• ALF due to shock liver, Cardiovascular support is the treatment of choice
• Budd-Chiari Syndrome
• Hepatic Vein thrombosis with ALF is an indication for transplant, provided underlying malignancy is excluded
• Malignant Infiltration
• Previous cancer history or massive hepatomegaly, consider underlying malignancy and obtain imaging and liver biopsy to confirm or exclude diagnosis
• Indeterminate Etiology
• If diagnosis remains in question after extensive evaluation, liver Bx may be appropriate
  

Intensive Care of ALF