Hepatic Failure/GI/Endocrine Emergencies

Patients with any degree of encephalopathy should be transferred to an ICU, ideally with contact to a

transplant center, because rapid progression can occur.

Diagnostic Work-up

Procedure

History

Assess timing of symptom onset

Assess for exposure history to viruses, drugs (e.g., acetaminophen), or toxins (e.g.,

mushrooms)

Assess substance abuse history

Physical examination

Normal signs of chronic liver disease (e.g., ascites, jaundice, right upper quadrant pain)

may not be present

Assess encephalopathy grade

Laboratory analysis

Basic metabolic panel, CBC, liver function tests, coagulation tests, arterial blood gas,

acetaminophen concentrations, ammonia, toxicology screen, blood typing

Viral serologies

Liver biopsy useful for determining autoimmune hepatitis or ALF associated with HSV

Imaging

Hepatic imaging studies (computed tomography [CT], ultrasonography) may be used to

detect a thrombus of the hepatic vein

ALF = acute liver failure; CBC = complete blood cell count; HSV = herpes simplex virus.

Cause of ALF

Proportion of Cases

Acetaminophen

46%

Indeterminate

12%

Non-acetaminophen drug induced

11%

Hepatitis B

7%

Autoimmune

7%

Ischemic

7%

Hepatitis A

1.5%

Wilson disease

1.2%

Pregnancy

1%

Budd-Chiari

0.7%

Other

7%

ALF = acute liver failure.

Acetaminophen

Acetaminophen overdose is responsible for almost 50% of ALF cases in the United States. Ace-

taminophen overdose is considered the primary cause of ALF in the United States and Europe, and

it was responsible for 70,000 health care encounters and 300 deaths in the United States in 2005.