1. Acute liver failure
Chirag Shah
Department of Gastroenterology
KEM Hospital

2. History
• YAS 30-year-old married woman
• Referred with
– Jaundice since 10 days
– No prodromal symptoms
– Altered sensorium since 3 days
• Progressive
• At admission – not responding to verbal commands

3. History
• No history of
– fever, pain in abdomen, nausea, vomiting
– mucosal bleeding, petechiae, ecchymosis
– jaundice, ascites, altered sensorium or GI bleed in past
• Past history
– fracture forearm at 15 years of age; underwent
surgery
– No history of blood transfusion, tattooing, dental
treatment or sexual promiscuity
• No history of addiction, recent drug ingestion

4. History
• LMP - 15 days back
• G2P2A0
• Birth history
– Third degree consanguinity

5. Examination
• Altered sensorium
– Not following verbal commands
• Temperature – normal
• Heart rate 62/min
• Respiratory rate 16/min, regular
• Icterus +
• Pallor +
• No clubbing, cyanosis, lymphadenopathy, neck
vein engorgement, pedal edema

6. Abdominal examination
• Liver – 2 cm palpable, firm with sharp
edge, smooth surface
• Spleen – not palpable
• No flank dullness
• No lump
• No dilated veins

7. CNS examination
• Altered sensorium
• GCS – 8/15
• No focal neurological deficit
• DTR – brisk
• Plantar reflex – equivocal
• Pupils semi-dilated – reacting to light

8. Clinical diagnosis
• Acute liver failure
• Etiology ?
– Viral hepatitis
• Hepatitis E
• Hepatitis B
• Hepatitis A
• Non A non E
– Wilson’s disease
– Autoimmune hepatitis

9. Investigations
• Hemoglobin 11.2 gm/dL
• Total count 16000/cumm
• Platelet count 1.6 lac/dL
• S. Na 142 mEq/L
• S. K 4.2 mEq/L
• S Creatinine 1.6 mg/dl
• BUN 30 mg/dL
• S. Ammonia 205 ng/L

10. Liver function test
Liver function test 15-12-11 day 5 of illness 20-12-11 day 10
Total bilirubin (mg/dL) 13.2 14.8
Direct bilirubin (mg/dL) 8.2 8.6
AST (IU/mL) 868 900
ALT (IU/mL) 375 452
Alkaline phosphatase 10 16
(IU/mL)
Total protein (g/dL) 7.4 7.3
Albumin (g/dL) 2.8 2.6
INR 4.2 4.5
GGT (IU/l) 27 25

11. Investigations
• Serology for hepatitis viruses
– HbsAg: Negative
– Ig M anti HBc antibody: Negative
– Anti HCV: Negative
– Ig M HEV: Negative
– Ig M HAV: Negative

12. Investigations
• S. ANA : Negative
• S. cerruloplasmin: 8 mg/dL (Normal value:20-
50mg/dl )
• 24 hour urinary copper: 110 mcg/24 h
• KF ring : Negative

13. Investigations
• USG abdomen
– Mild hepatomegaly with altered echotexture
– Mild splenomegaly
– Mild ascites
• Hepatoportal doppler
– Hepatic veins patent
– IVC patent
– Portal vein 10 mm
– No collaterals

14. Course during hospitalization
• Patient deteriorated neurologically
• Now, on ventilatory support
• Requires transplant
• But not affording ……