Autoimmune Hepatitis
����Consider patients with coagulopathy and mild hepatic encephalopathy
due to autoimmune hepatitis for corticosteroid treatment (prednisone,
40-60 mg/day) (III).
����Perform liver biopsy when autoimmune hepatitis is suspected as the
cause of acute liver failure and autoantibodies are negative (III).
����Consider for transplantation patients with autoimmune hepatitis even
while corticosteroids are being administered (III).
Ischemic Injury
����In ALF patients with evidence of ischemic injury, cardiovascular
support is the treatment of choice (III).
Hepatic Vein Thrombosis
����Hepatic vein thrombosis with acute hepatic failure is an indication for
liver transplantation, provided underlying malignancy is excluded (II-3).
Wilson Disease
����To exclude Wilson disease one should obtain ceruloplasmin, serum
and urinary copper levels, slit lamp examination for Kayser-Fleischer
rings, hepatic copper levels when liver biopsy is feasible, and total
bilirubin/alkaline phosphatase ratio (III).
Note: Patients in whom Wilson disease is the likely cause of acute liver failure must be
promptly considered for liver transplantation (III).
Malignancy
����In patients with acute liver failure who have a previous cancer history
or massive hepatomegaly, consider underlying malignancy and obtain
imaging and liver biopsy to confirm or exclude the diagnosis (III).
Central Nervous System
����Cerebral edema and intracranial hypertension (ICH) have long been
recognized as the most serious complications of acute liver failure.
Table 3. Grades of Encephalopathy
Grade
Definition
I
Changes in behavior with minimal change in level of consciousness
II
Gross disorientation, drowsiness, possibly asterixis, inappropriate behavior
III
Marked confusion; incoherent speech, sleeping most of the time but
arousable to vocal stimuli
IV
Comatose, unresponsive to pain, decorticate or decerebrate posturing
Note: some patients will overlap grades; clinical judgment is required.
Adapted from Conn HO, Leevy CM, Vhlahcevic ZR, Rodgers JB, Maddrey WC, Seeff L, Levy LL.
Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy.
A double blind controlled trial. Gastroenterology. 1977;72:573-583.
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