Insuficiencia hepática aguda

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Antecedentes

Anatomía vascular del hígado.

Definiciones

  • Insuficiencia hepática hiperaguda: la encefalopatía ocurre dentro de los 7 días del inicio de la ictericia; este subgrupo es probable que sobreviva con manejo médico a pesar de la alta incidencia de edema cerebral[1]
  • Insuficiencia hepática aguda: intervalo de 8-28 días desde la ictericia hasta la encefalopatía; este subgrupo tiene una alta incidencia de edema cerebral y un peor pronóstico sin trasplante de hígado[2]
  • Insuficiencia hepática subaguda: intervalo de 5-12 semanas desde el inicio de la ictericia hasta el inicio de la encefalopatía; este subgrupo tiene una menor incidencia de edema cerebral, pero un mal pronóstico[3]


Causas de hepatitis aguda

Drug or Toxin Related Liver Disease


Otras Causas Raras de Insuficiencia Hepática Aguda

  • Wilson's disease: elevaciones inexplicadas en las pruebas de función hepática, síntomas neuropsiquiátricos, anillos de Kayser-Fleischer en el examen ocular
  • Autoimmune hepatitis: más común en mujeres, enfermedad hepática sin explicación, puede tener antecedentes familiares de otros trastornos autoinmunes
  • Hemochromatosis: antecedentes familiares de enfermedad hepática y enfermedad cardíaca
  • Budd-Chiari: historia de trastorno hipercoagulable, dolor abdominal y ascitis


Características clínicas

Ictericia de la piel
Angioma en araña
Ascitis secundaria a cirrosis.
Ictericia pediátrica con ictericia de la esclera.
  • Hallazgos comunes en la insuficiencia hepática aguda
  • Hallazgos comunes en la insuficiencia hepática crónica
    • Ascitis
    • Caput medusae
    • Eritema palmar
    • Angiomas en araña
    • Ginecomastia
    • Atrofia testicular
    • Enlargement de la glándula parótida
    • Atrofia muscular
    • También puede tener ictericia, encefalopatía, y asterixis como en la insuficiencia hepática aguda


Diagnóstico diferencial

Encefalopatía (cambio en el estado mental)


Ictericia

Hepatic Dysfunction

Infectious

Neoplastic

Metabolic

Biliary

  • Biliary cirrhosis

Drugs

Miscellaneous


Evaluation


Labs

  • LFTs
    • AST and ALT
      • Enzymes found mainly in hepatic cells, though ALT is more specific to the liver than AST
      • Extreme elevation in AST (>3000U/L, or >40x upper limit of normal) is consistent with acetaminophen toxicity or ischemic injury
      • Moderate elevations (10-40x upper limit of normal) is consistent with viral hepatitis
      • Mild elevations (<10x upper limit of normal) is consistent with alcoholic hepatitis
    • Alkaline Phosphatase
      • Found in bile canaliculi (but also in placenta, ileal mucosa, bone, and kidney)
      • Elevated in diseases of cholestasis
      • Rare for levels to be >3x normal limit in acute liver failure
    • Bilirubin
      • Elevated in diseases of cholestasis
      • In obstructive diseases, the direct bilirubin will usually be about 50% of the total bilirubin; if indirect bilirubin is higher, more suggestive of hemolysis or problem with conjugation
  • Coagulation Studies
    • Reflects the liver’s ability to synthesize clotting factors
    • INR >6.5 or PT >20 seconds indicates patients at high risk for death
  • Albumin
    • Reflects synthetic function of the liver
    • Has a long half-life (20 days) and may not be decreased early in disease
  • Ammonia
    • Elevated as a result of impaired clearance
    • Poor correlation between degree of elevation and severity of encephalopathy symptoms
  • Chemistry Panel
    • Electrolyte abnormalities may indicate malnutrition or dehydration
    • Creatinine is used as a prognostic indicator
    • Need to check a glucose because patients with liver failure are prone to hypoglycemia
  • CBC
  • Viral hepatitis Serologies
    • Consider for all patients with undifferentiated liver failure
    • IgM anti-HBc may be the only positive marker in acute Hepatitis B infection
    • Anti-HCV and HCV RNA are present in both chronic and acute Hepatitis C infections, so it is difficult to differentiate based on serologies, but presence of HCV RNA in the absence of anti-HCV is more suggestive of acute infection[7]
    • Only need to test for IgM anti-HEV in patients who are symptomatic and have just travelled from areas where Hepatitis E is endemic


Imaging

  • Consider RUQ US or CT in patients with jaundice to evaluate for a mechanical obstruction
  • Otherwise, tailor imaging towards specific complaints

Ascites Diagnosis

The differential diagnosis of ascites is often clarified by the calculation of the serum albumin to ascites gradient (SAAG).^

^SAAG = (serum albumin in g/dL) − (ascitic albumin in g/dL)


Management

  • Treatment is mostly supportive and tailored towards the specific etiology
  • Early consideration regarding transporting patient to a transplant center given potential for rapid deterioration
  • Symptom specific supportive treatment options


Disposition

  • Admission to ICU with early consideration for transportation to transplant center


See Also


References

  1. ↑ O’Grady, JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. July 1993, Volume 342, Issue 8866, Page 273-275
  2. ↑ O’Grady, JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. July 1993, Volume 342, Issue 8866, Page 273-275
  3. ↑ O’Grady, JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. July 1993, Volume 342, Issue 8866, Page 273-275
  4. ↑ Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
  5. ↑ Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204
  6. ↑ Tintanelli's
  7. ↑ Bailey, C, Hern HG. Hepatic Failure: An Evidence-Based Approach In The Emergency Department. Emergency Medicine Practice. Vol. 12, No. 4, 2014.
  8. ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
  9. ↑ Runyon BA. Cardiac ascites: a characterization. J Clin Gastro. 1998; 10(4): 410-412.
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