38 year old man previously healthy with:

1.

Hepatic encephalopathy – confusion, low GCS (may also be worsened by hypoglycaemia)

Tachycardia, normal BP (compensated) – reflects delirium, haemodynamic compromise

Hepatitis (non obstructive)- very elevated ALT,AST and elevated bilirubin with relatively normal GGT/ALP due to hepatocellular breakdown

High INR, low glucose and low albumin reflect poor synthetic function

Hypoglycaemia requires ivi replacement with initial 3-5 mls/kg of 10% Dextrose, with regular monitoring

2. Causes:

Infection – viral (Hepatitis A,B,C/EBV/CMV/HSV/HIV)

Toxins – alcohol, paracetamol, mushroom, CCl4

Drugs – antibiotics, NSAIDs, antiepileptics (phenytoin), cocaine, ecstacy

Other – vascular (ischaemic, portal vein thrombosis etc), malignancy (primary, secondary), metabolic (alpha1 antitrypsin deficiency, Wilson’s disease etc)

3. Good supportive care +/- ICU/HDU level care:

Careful attention to fluid management and haemodynamics.

Monitoring of metabolic parameters – replace glucose

Surveillance for infection

Maintenance of nutrition

Prompt recognition of gastrointestinal bleeding

In general, liver failure plus any other illness equals death. Even with intensive care level support.