Classification of hepatic encephalopathy
- Grade 0: No abnormality detected
- Grade 1: trivial lack of awareness, euphoria or anxiety, impaired addition and
substraction - Grade 2: lethargy or apathy, disorientation to time, personality change, inappropriate
behaviour - Grade 3: somnolence to semistupor, responsiveness to stimuli, confusion, gross
disorientation, bizarre behaviour - Grade 4: coma
Definition of acute liver injury
Sudden loss of hepatic function in a patient with no preexisting liver disease.
Coagulopathy INR>1.5 and a degree of encephalopathy within 6months of initial symptoms.
Causes of ALI
VITALS
- Toxins and Drugs: paracetamol, INZ, rifampicin, alcohol, mushrooms, herbal supplements
- Infections - viruses mostly Hepatitis, EBV, Malaria, leptospirosis
- Vascular / ischemia (Acute budd-chiaroscuro syndrome, CCF RVF
- Liver infiltration/ Metabolic (Wilson, )
- Autoimmune (autoimmune hepatitis
- Systemic/Septic/ shock liver
- Idiopathic
Investigations in a patient suspected of ALF
Bedside: ABG, glucose, urine dipstick, pregnancy
Bloods: FBC, UEC, CMP, glucose, amylase/lipase,
- hepatic panel Heps
-clotting profile INR, PT/PTT, fibrinogen
-toxicology- paracetamol, alcohol and urine tox
Arterial ammonia is more related to degree of HE, however venous ammonia is
routinely done
Autoimmune markers
Serum cerulopasmin (24-hour urine)
CT scan if HE grade 3 or 4, or if sudden change in mental state
Complications of ALF
Intracranial hypertension
Herniating
Decreased SVR
Infection
ARDS
Criteria for poor prognosis in ALF
Paracetamol induced
ph<7.3 after fluid resusc
All of:
PT>100 (INR>6.5)
Creatinine>300 mmol/L
Grade 3 or 4 encephalopathy
Non-Paracetamol induced
INR >6.5
Any 3 of:
-Non-A, Non-B viral hepatitis or
indeterminate etiology
-Time jaundice-to-encephalopathy>7
days
-Age<10 y/o or >40 y/o
PT> 50 (INR> 3.5)
-Total bilirubin>30 mmol/L
