01Approach to the Critical Patient/attcp55

Immediate priorities

›Acute liver failure recognition

›Encephalopathy plus coagulopathy

›Confusion, somnolence, sleep-wake reversal

›Asterixis on exam

›INR > 1.5 without anticoagulant

›Deep jaundice trajectory

›Bilirubin > 171 umol/l and rising

›Jaundice preceding encephalopathy

›If encephalopathy plus INR > 1.5, treat as acute liver failure until excluded

›Viral ALF spontaneous survival only about 25 percent

›Early transplant center transfer is critical

›Airway and neurologic threats

›Worsening encephalopathy grade

›Grade III to IV with loss of airway protection

›Aspiration risk with declining mental status

›If grade III to IV encephalopathy, definitive airway control

›Rapid sequence intubation preparation

›Head of bed elevation to 30 degrees

›Metabolic and circulatory threats

›Hypoglycemia from hepatic failure

›Point of care glucose immediately

›Dextrose infusion if low

›Hemodynamic instability

›Hypotension and bradycardia reported in acute HAV

›Tachycardia from dehydration or sepsis

›If shock physiology, resuscitate and seek alternate source

›Vasopressor for refractory hypotension

02History/hx62

Presentation pattern

›Prodromal phase

›Constitutional symptoms

›Fever and malaise

›Fatigue and anorexia

›Myalgias and arthralgias

›Serum sickness-like prodrome in HBV

›Arthralgias

›Urticarial rash

›Icteric phase

›Jaundice and dark urine

›Cola-colored urine

›Scleral icterus onset

›Acholic stools

›Pale clay-colored stools

›Cholestatic pattern clue

›Right upper quadrant or epigastric pain

›Dull aching quality

›Hepatomegaly correlation

›Pruritus

›Bile salt deposition

›Prolonged in cholestatic HAV

Exposure and risk history

›Incubation and timing

›HAV about 28 days, range 15 to 50

›HBV about 90 days, range 30 to 180

›HCV about 45 days, range 14 to 180

›HEV about 40 days, range 15 to 60

03Physical Exam/exam48

Vital signs and general

›Stability snapshot

›Temperature

›Fever in prodromal phase

›Persistent fever after jaundice suggests alternate diagnosis

›Heart rate and blood pressure

›Bradycardia and hypotension reported in acute HAV

›Tachycardia if dehydrated

›Glucose

›Hypoglycemia as ALF marker

›Point of care check

›General appearance

›Ill-appearing and jaundiced

›Icteric sclerae

›Jaundiced skin

›Excoriations from pruritus

›Cholestatic itch

›Skin trauma

Abdominal and skin exam

›Abdominal findings

›Right upper quadrant tenderness

›Hepatic capsule stretch

›Guarding uncommon

›Hepatomegaly

›Present in about 78 percent of HAV cases

›Smooth tender liver edge

›Splenomegaly

›Suggests chronic disease or EBV

04Differential Diagnosis/ddx44

Life-threatening and hepatotoxic mimics

›Toxic and ischemic causes

›Acetaminophen toxicity

›Most common cause of ALF in the US

›Check level and ingestion history

›Ischemic hepatitis

›AST and ALT often above 1000 with rapid decline

›History of hypotension, shock, heart failure

›Drug-induced liver injury

›Amoxicillin-clavulanate and isoniazid

›Supplements and NSAIDs

›Can mimic viral hepatitis exactly

›Metabolic and autoimmune

›Autoimmune hepatitis

›ANA and anti-smooth muscle antibody

›Elevated IgG

›Wilson disease

›Consider in patients under 40 years

›Low ceruloplasmin and Kayser-Fleischer rings

›Alcoholic hepatitis

›AST to ALT ratio above 2 to 1

›AST usually below 300 with elevated GGT

Infectious and obstructive mimics

›Non-hepatotropic infections

›EBV and CMV

›Atypical lymphocytes

›Lymphadenopathy

›HSV hepatitis

05Laboratory Tests/lt60

Core liver and synthetic function

›Liver panel

›Aminotransferases

›AST and ALT often above 10 times ULN in acute viral hepatitis

›Hepatocellular pattern

›Bilirubin

›Total and direct bilirubin

›Bilirubin above 171 umol/l marks severe course

›Cholestatic markers

›Alkaline phosphatase

›GGT

›Albumin

›Synthetic function marker

›Low in chronic disease

›Coagulation and severity

›PT and INR

›INR above 1.5 is a critical ALF threshold

›Reflects hepatic synthetic failure

›Glucose

›Hypoglycemia in ALF

›Frequent monitoring

Etiologic serologies

›First-line viral serologies

›HAV

›Anti-HAV IgM confirms acute infection

›Anti-HAV IgG reflects immunity

›HBV

›HBsAg plus anti-HBc IgM confirms acute HBV

06Diagnostic Tests/dt59

Scoring Systems

›Severity and pattern tools

›R-value pattern

›ALT over ULN divided by ALP over ULN

›R above 5 hepatocellular pattern typical of viral hepatitis

›R below 2 cholestatic and 2 to 5 mixed

›MELD score

›Bilirubin, INR, creatinine, sodium inputs

›Severity stratification and transplant listing

›King's College Criteria for non-acetaminophen ALF

›INR above 6.5 alone

›Any 3 of age under 10 or over 40, unfavorable etiology, jaundice over 7 days before encephalopathy, INR above 3.5, bilirubin above 300 umol/l

›Prognostic adjuncts

›ALFSG Prognostic Index

›Encephalopathy grade, etiology, vasopressor use, bilirubin, INR

›AUROC 0.843 for spontaneous survival

›Limitations

›Scores supplement not replace clinical trajectory

›Serial reassessment required

MRI

›MRI and MRCP role

›Limited acute utility

›Diagnosis of acute viral hepatitis is serologic

›Reserve for problem solving

›Problem-solving indications

›Suspected biliary obstruction on ultrasound

›Vascular pathology such as Budd-Chiari

›Contraindications and limits

07Disposition/dispo40

Level of care selection

›Admission indications

›Coagulopathy or encephalopathy

›INR above 1.5

›Any encephalopathy even subtle

›Inability to maintain oral intake

›Intractable vomiting

›Dehydration requiring IV fluids

›Deep jaundice with worsening trajectory

›Bilirubin above 171 umol/l and rising

›Hypoglycemia or renal insufficiency

›High-risk comorbidity

›Pre-existing liver disease

›Immunosuppression or pregnancy

›Transfer and ICU criteria

›Transfer to transplant center for ALF

›Coagulopathy plus encephalopathy

›Viral ALF spontaneous survival about 25 percent

›ICU admission

›Grade III to IV encephalopathy

›Hemodynamic instability

Discharge criteria and follow up

›Outpatient criteria

›Synthetic function preserved

›INR below 1.5

›Normal mental status

›Tolerating oral intake

›Adequate hydration

08Treatment/t59

Initial stabilization

›Supportive measures

›IV fluids for dehydration

›Correct electrolyte abnormalities

›Treat hypoglycemia with dextrose

›Antiemetics for nausea and vomiting

›Ondansetron 4 mg IV every 8 hours as needed

›Avoid hepatotoxic alternatives

›Avoid hepatotoxic medications

›Hold or limit acetaminophen to under 2 g per day

›Avoid NSAIDs and statins

›Discontinue herbal and dietary supplements

Acute liver failure management

›If ALF criteria met, intensive support

›N-acetylcysteine

›Improves transplant-free survival in early coma grades even in non-acetaminophen ALF

›IV loading 150 mg/kg over 1 hour

›Then 12.5 mg/kg/hour for 4 hours

›Then 6.25 mg/kg/hour maintenance

›ICU admission and transplant referral

›Early transplant center contact

›Intracranial pressure monitoring if grade III to IV

›Glucose and coagulopathy support

›Continuous dextrose for hypoglycemia

›Vitamin K and reserve plasma for active bleeding

Virus-specific therapy

›HAV and HEV

›Supportive care only

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›HEV severity in pregnancy

›Up to 25 percent mortality in third trimester

›Aggressive monitoring and transfer

›Vertical transmission risk

›HBV perinatal transmission high without prophylaxis

›Neonatal HBIG plus vaccine

›Antiviral safety

›Tenofovir preferred antiviral in pregnancy for HBV

›Avoid ribavirin due to teratogenicity

›Maternal monitoring

›Serial INR and mental status

›Obstetric and hepatology co-management

Geriatric

›Older adult features

›Higher severe disease risk

›Age over 40 increases HAV severity

›Pre-existing liver disease prevalence

›Atypical presentation

›Delirium as encephalopathy

›Blunted febrile response

›Medication and comorbidity

›Polypharmacy with hepatotoxins

›Dose adjustment for renal function

›Disposition bias toward admission

›Limited physiologic reserve

›Dehydration risk

10Background/b52

Epidemiology

›Burden and distribution

›Etiology varies by region and risk

›HAV and HEV fecal-oral

›HBV, HCV, HDV parenteral and sexual

›Outbreak patterns

›HAV foodborne and community outbreaks

›Person-to-person spread in unvaccinated populations

›Chronicity rates

›HBV about 5 percent chronicity in adults

›HCV about 55 to 85 percent chronicity

›Severity epidemiology

›ALF incidence

›Under 1 percent in HAV

›0.1 to 0.5 percent in HBV

›Spontaneous clearance

›About 25 percent in acute HCV

›Over 95 percent recovery in acute HBV adults

Pathophysiology

›Mechanisms of injury

›Immune-mediated hepatocyte injury

›Cytotoxic T-cell response

›Necroinflammation

›Cholestatic component

›Canalicular dysfunction

›Pruritus and acholic stools

›Synthetic failure in severe disease

›Coagulopathy from reduced clotting factor synthesis

11Patient Discharge Instructions/pdi21

copy discharge instructions

›Home care

›Rest and stay well hydrated

›Eat small frequent meals if nauseated

›Avoid alcohol completely until full recovery

›Avoid acetaminophen and other liver-stressing medicines and supplements

›Return to ER immediately for

›Confusion, excessive drowsiness, or personality change

›Worsening yellow skin or eyes, very dark urine, or pale stools

›Inability to keep fluids down

›Easy bruising or bleeding

›Abdominal swelling

›Preventing spread

›Wash hands well after using the toilet

›Do not share needles, razors, or toothbrushes

›Use barrier protection during sex until cleared

›Hepatitis A is generally noninfectious about 1 week after jaundice starts

›Follow up

›Repeat blood tests within 1 to 2 weeks

›See liver specialist as arranged

›Most hepatitis A recovers within 2 months

›Some people have prolonged symptoms up to 6 months

12References/r12

Guidelines and key sources

›Guideline sources

›AASLD acute liver failure guidelines

›AASLD hepatitis B guidance

›ACG evaluation of abnormal liver chemistries

›ACOG viral hepatitis in pregnancy clinical practice guideline

›Evidence summaries

›Reviews on hepatitis A and E treatment options

›Cochrane review of pharmacologic interventions for acute hepatitis B

›ACR Appropriateness Criteria for abnormal liver function tests

›Coding standards

›ICD-10 B15 to B17 acute viral hepatitis codes

›SNOMED CT acute viral hepatitis concept

Evidence & Review

Evidence & Review