A previously well 38 year old male presents with a 1 week history of vomiting, diarrhoea and abdominal pain. On presentation he is drowsy and confused. T 37 HR 110 BP 120/70 Sats 96% RA GCS12.

The above LFT’s show a hepatitis type picture with a raised bilirubin and a markedly elevated ALT and AST, with a mildly elevated GGT and ALP. The elevated INR, low albumin and low BSL are signs of synthetic dysfunction of the liver. The synthetic dysfunction and confusion (suggestive of encephalopathy) are signs that the patient has acute liver failure and the fact that the patient was previously well, indicates they are in fulminant liver failure. The term fulminant hepatic failure is generally used to describe the development of encephalopathy within 8 weeks of the onset of symptoms in a patient with a previously healthy liver.

The causes of acute liver failure are extensive with paracetamol overdose and viral hepatitis being the most common.  Other causes include :

Infections – viral (Hep A,B,C,D,C,E, EBV, CMV, Yellow Fever). Non Viral (Toxoplasmosis, Leptospirosis, Q Fever, mycoplasma)

Drugs – Paracetamol, Halothane, Methoxyflurane, NSAID, Phenytoin

Toxins – alcohol (AST:ALT <2 in this case, therefore not likely due to alcohol), mushrooms (Amanita phaloides), Carbon tetrachloride

Metabolic -Wilsons disease, pregnancy, Reyes syndrome

Complications and management:

• Decreased LOC – CT head to look for cerebral oedema, bleeds. Airway control and neuroprotective strategies
• Low BSL -treat with dextrose
• Hypovolaemic shock – vasopressors
• Bleeding (GI or intracranial) – FFP and platelets
• Hepatorenal syndrome
• Bacterial infections – antibiotics
• Search for and treat underlying cause