Fulminant Hepatitis

Aka: Fulminant Hepatitis, Acute Hepatic Failure, Acute Liver Failure

1. Pathophysiology
   1. Massive hepatic necrosis within 8 weeks of onset
2. Causes
   1. Infectious Disease
      1. Viral Hepatitis
         1. Hepatitis A
         2. Hepatitis B
         3. Hepatitis C
         4. Hepatitis D
      2. Bacterial infection
      3. Rickettsial infection
      4. Parasitic infection
   2. Toxic Hepatitis (drug or Hepatotoxin exposure)
   3. Ischemia or shock
   4. Budd-Chiari Syndrome
   5. Idiopathic Chronic Active Hepatitis
   6. Wilson's Disease (Acute)
   7. Microvesicular Steatosis (Fat) Syndromes
      1. Nonalcoholic Fatty Liver
      2. Acute Fatty Liver of Pregnancy
      3. Reye's Syndrome
3. Symptoms
   1. Vomiting
   2. Upper Abdominal Pain
   3. Anorexia
   4. Jaundice
4. Signs
   1. Neurologic changes (Hepatic Encephalopathy)
      1. Altered Level of Consciousness (Delirium, coma)
      2. Decerebrate rigidity (with severe cerebral edema)
      3. Personality change
   2. Jaundice
   3. Coagulopathy
   4. Bleeding (e.g. Gastrointestinal Bleeding)
   5. Acute Renal Failure (Hepatorenal Syndrome)
   6. Hypoglycemia
   7. Acute Pancreatitis
   8. Cardiopulmonary failure
   9. Ascites (due to Portal Hypertension)
5. Prognosis: Factors associated with poor outcomes
   1. Advanced age
   2. Halothane exposure
   3. Hepatitis C
   4. Coma (80% Mortality)
   5. Rapid decrease in liver span
   6. Respiratory failure
   7. Marked ProTime prolongation
   8. Factor V Level <20%
6. Management
   1. ABC Management
      1. Endotracheal Intubation often required
   2. Monitor Serum Glucose
      1. Correct Hypoglycemia with IV D10 or D20 prn
   3. Prevent GI Bleed
      1. H2 Blockers to maintain gastric pH >3.5
   4. Intracranial Pressure (questionable efficacy)
      1. Lower Intracranial Pressure with Mannitol IV prn
   5. Liver Transplant Indications
      1. Grade 3-4 Encephalopathy
      2. Adverse prognostic indicators as above