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==Differentiating Acute Liver Failure from other Diseases==
==Differentiating Acute Liver Failure from other Diseases==
Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy.<ref name="pmid17370334">{{cite journal| author=Escorsell A, Mas A, de la Mata M, Spanish Group for the Study of Acute Liver Failure| title=Acute liver failure in Spain: analysis of 267 cases. | journal=Liver Transpl | year= 2007 | volume= 13 | issue= 10 | pages= 1389-95 | pmid=17370334 | doi=10.1002/lt.21119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17370334  }} </ref><ref name="pmid17608778">{{cite journal| author=Bower WA, Johns M, Margolis HS, Williams IT, Bell BP| title=Population-based surveillance for acute liver failure. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 11 | pages= 2459-63 | pmid=17608778 | doi=10.1111/j.1572-0241.2007.01388.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608778  }} </ref><ref name="pmid20196116">{{cite journal| author=Kumar R, Shalimar. Bhatia V, Khanal S, Sreenivas V, Gupta SD et al.| title=Antituberculosis therapy-induced acute liver failure: magnitude, profile, prognosis, and predictors of outcome. | journal=Hepatology | year= 2010 | volume= 51 | issue= 5 | pages= 1665-74 | pmid=20196116 | doi=10.1002/hep.23534 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20196116  }} </ref><ref name="pmid22213561">{{cite journal| author=Lee WM, Stravitz RT, Larson AM| title=Introduction to the revised American Association for the Study of Liver Diseases Position Paper on acute liver failure 2011. | journal=Hepatology | year= 2012 | volume= 55 | issue= 3 | pages= 965-7 | pmid=22213561 | doi=10.1002/hep.25551 | pmc=3378702 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22213561  }} </ref>
Acute liver failure must be differentiated from other diseases that cause signs and symptoms of [[jaundice]], [[coagulopathy]], and [[encephalopathy]].<ref name="pmid17370334">{{cite journal| author=Escorsell A, Mas A, de la Mata M, Spanish Group for the Study of Acute Liver Failure| title=Acute liver failure in Spain: analysis of 267 cases. | journal=Liver Transpl | year= 2007 | volume= 13 | issue= 10 | pages= 1389-95 | pmid=17370334 | doi=10.1002/lt.21119 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17370334  }} </ref><ref name="pmid17608778">{{cite journal| author=Bower WA, Johns M, Margolis HS, Williams IT, Bell BP| title=Population-based surveillance for acute liver failure. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 11 | pages= 2459-63 | pmid=17608778 | doi=10.1111/j.1572-0241.2007.01388.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608778  }} </ref><ref name="pmid20196116">{{cite journal| author=Kumar R, Shalimar. Bhatia V, Khanal S, Sreenivas V, Gupta SD et al.| title=Antituberculosis therapy-induced acute liver failure: magnitude, profile, prognosis, and predictors of outcome. | journal=Hepatology | year= 2010 | volume= 51 | issue= 5 | pages= 1665-74 | pmid=20196116 | doi=10.1002/hep.23534 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20196116  }} </ref><ref name="pmid22213561">{{cite journal| author=Lee WM, Stravitz RT, Larson AM| title=Introduction to the revised American Association for the Study of Liver Diseases Position Paper on acute liver failure 2011. | journal=Hepatology | year= 2012 | volume= 55 | issue= 3 | pages= 965-7 | pmid=22213561 | doi=10.1002/hep.25551 | pmc=3378702 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22213561  }} </ref>
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Revision as of 16:49, 1 December 2017

Acute liver failure Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Overview

Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy. The differentials include acute hepatitis, cholestatic jaundice, and hemolytic jaundice. The common causes of acute hepatitis causing acute liver failure include acetaminophen toxicity, viral hepatitis, alcoholic hepatitis, autoimmune hepatitis, acute fatty liver of pregnancy, Wilson's disease, ischemic hepatitis and hepatic congestion due to right heart failure and Budd–chiari syndrome.

Differentiating Acute Liver Failure from other Diseases

Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy.[1][2][3][4]

Condition Differentiating signs and symtoms Differentiating Tests
Acute hepatits
  • Severe acute hepatitis is followed very closely as it has a potential to develop into acute or subacute hepatic failure.
  • Acute hepatitis would not be considered acute liver failure unless hepatic encephalopathy is present.
  • Common causes are viral hepatitis, acetaminophen overdose, alcoholic hepatitis, autoimmune hepatitis and metabolic disorders such as Wilson's disease and hemochromatosis.
  • Hepatic encephalopathy is absent.
  • Grades of hepatic encephalopathy are:
    • Grade 1: Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition. 67% of cirrhotic patients may have 'minimal hepatic encephalopathy.
    • Grade 2: Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behavior; impaired performance of subtraction.
    • Grade 3:  Somnolence to semi-stupor, but responsive to verbal stimuli; confusion; gross disorientation.
    • Grade 4:  Coma (unresponsive to verbal or noxious stimuli).
Cholestasis
  • Jaundice can be seen due to Intra or extrahepatic biliary obstruction, as well as intrahepatic cholestasis due to conditions like drug-induced liver injury..
  • The absence of hepatic encephalopathy and coagulopathy will differentiate it from acute liver failure.
  • Absence of hepatic encephalopathy.
  • Normal PT/INR.
Hemolysis
  • May have jaundice with increased indirect (unconjugated) serum bilirubin.
  • Liver dysfunction may not be present. So, coagulopathy and hepatic encephalopathy would not be there.
  • Common examples are hemolytic anemias.
  • Absence of hepatic encephalopathy.
  • Normal PT/INR.
  • Abnormal peripheral blood smear.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CT= Computed tomography

Classification of jaundice based on etiology Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
Family history Fever RUQ Pain Pruritis AST ALT ALK BLR Indirect BLR Direct Viral serology
Jaundice Hepatocellular Jaundice Hemochromatosis + - -/+ - ↑ ↑ ↑/N ↑/N N - Ferritin ↑ Liver biopsy
Wilson's disease + - -/+ - ↑ ↑ N ↑/N N - Serum cerulloplasmin ↑ Liver biopsy
Viral hepatitis - -/+ - - ↑ ↑↑ N ↑/N N + Specific viral antibody for each type -
Alcoholic hepatitis - - - - ↑↑ ↑ N ↑/N N - - -
Drug induced hepatitis - -/+ - - ↑ ↑ N ↑/N N - - -
Autoimmune hepatitis -/+ - - -/+ ↑ ↑ N ↑/N N - Anti-LKM antibody Liver biopsy
Cholestatic Jaundice Common bile duct stone -/+ - + + N N ↑ N ↑ - Dilated ducts on sono CT/ERCP
Hepatitis A cholestatic type - -/+ + + N N ↑ N ↑ + HAV- AB Abdominal ultrasound
EBV / CMV hepatitis - -/+ + + N N ↑
N
↑ + Positive serology
Primary biliary cirrhosis -/+ - -/+ + N/↑ N/↑ ↑ ↑? ↑ - AMA positive Liver biopsy
Primary sclerosing cholangitis -/+ - -/+ + N/↑ N/↑ ↑ ↑? ↑ - Beading on MRCP Liver biopsy
Isolated Jaundice Crigler-Najjar type 2 + - - - N N N ↑ N - Genetic testing
Gilbert + - - - N N N ↑ N - Genetic testing
Rotor syndrome + - - - N N N N ↑ - Genetic testing Liver biopsy
Dubin-Johnson syndrome + - - - N N N N ↑ - Genetic testing Liver biopsy
Hereditory spherocytosis + - -/+ - N N N ↑ N - Genetic testing Osmotic fragility
G6PD deficiency + - - - N N N ↑ N - Genetic testing
Thalassemia + - - - N N N ↑ N - Genetic testing
Sickle cell disease + - - - N N N ↑ N - Genetic testing
Paroxismal nocturnal hemoglobinoria - - - - N N N ↑ N - Flocytometery
Immune hemolysis - -/+ - - N N N ↑ N - Autoantibodies
Hematoma - -/+ - - N N N ↑ N - Anemia Truma or surgery in history
Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
AST ALT ALK BLR Indirect BLR Direct Viral serology
Type of jaundice Pruritis RUQ pain Fever Family history
Common bile duct stone Cholestatic Jaundice + + - -/+ N N ↑ N ↑ - Dilated ducts on sono CT/ERCP
Hepatitis A cholestatic type + + -/+ - N N ↑ N ↑ + HAV- AB Abdominal ultrasound
EBV / CMV hepatitis + + -/+ - N N ↑ N ↑ + Positive serology PCR or ELISA
Primary biliary cirrhosis + -/+ - -/+ N/↑ N/↑ ↑ N ↑ - AMA positive Liver biopsy
Primary sclerosing cholangitis + -/+ - -/+ N/↑ N/↑ ↑ N ↑ - Beading on MRCP Liver biopsy

References

  1. ↑ Escorsell A, Mas A, de la Mata M, Spanish Group for the Study of Acute Liver Failure (2007). "Acute liver failure in Spain: analysis of 267 cases". Liver Transpl. 13 (10): 1389–95. doi:10.1002/lt.21119. PMID 17370334.
  2. ↑ Bower WA, Johns M, Margolis HS, Williams IT, Bell BP (2007). "Population-based surveillance for acute liver failure". Am J Gastroenterol. 102 (11): 2459–63. doi:10.1111/j.1572-0241.2007.01388.x. PMID 17608778.
  3. ↑ Kumar R, Shalimar. Bhatia V, Khanal S, Sreenivas V, Gupta SD; et al. (2010). "Antituberculosis therapy-induced acute liver failure: magnitude, profile, prognosis, and predictors of outcome". Hepatology. 51 (5): 1665–74. doi:10.1002/hep.23534. PMID 20196116.
  4. ↑ Lee WM, Stravitz RT, Larson AM (2012). "Introduction to the revised American Association for the Study of Liver Diseases Position Paper on acute liver failure 2011". Hepatology. 55 (3): 965–7. doi:10.1002/hep.25551. PMC 3378702. PMID 22213561.

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