Autoimmune Hepatitis
ÎConsider patients with coagulopathy and mild hepatic encephalopathy due to autoimmune hepatitis for corticosteroid treatment (prednisone, 40-60 mg/day) (III).
ÎPerform liver biopsy when autoimmune hepatitis is suspected as the cause of acute liver failure and autoantibodies are negative (III).
ÎConsider for transplantation patients with autoimmune hepatitis even while corticosteroids are being administered (III).
Ischemic Injury
ÎIn ALF patients with evidence of ischemic injury, cardiovascular support is the treatment of choice (III).
Hepatic Vein Thrombosis
ÎHepatic vein thrombosis with acute hepatic failure is an indication for liver transplantation, provided underlying malignancy is excluded (II-3).
Wilson Disease
ÎTo 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
ÎIn 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
ÎCerebral 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 II IV
Changes in behavior with minimal change in level of consciousness Gross disorientation, drowsiness, possibly asterixis, inappropriate behavior
III Marked confusion; incoherent speech, sleeping most of the time but arousable to vocal stimuli
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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