Rosen & Barkin's 5-Minute Emergency Medicine Consult (337 page)

• Nonalcoholic fatty liver disease
  
• Cholecystitis and cholangitis
  
• Reye syndrome
  
• Liver abscess
  
• Wilson disease
  
• Heat stroke
  
• Fitz-Hugh—Curtis syndrome
  
• Ischemic hepatitis (“shock liver”)
  
• Congestive heart failure
  
• Hemochromatosis
  
• Budd–Chiari syndrome
  

TREATMENT

ABCs and IV fluid resuscitation for FHF and severe hepatic encephalopathy.

• Treat hypovolemia judiciously with isotonic fluids
  
• Correct electrolyte imbalance
  
• Treat vomiting with ondansetron and metoclopramide
  
• Avoid hepatotoxic agents: Acetaminophen, alcohol, phenothiazines
  
• Avoid medications metabolized by liver
  
  • Propofol for sedation preferred
    
  • Fentanyl for pain preferred
    
• Correct coagulopathy if active bleeding.
  
• N-acetylcystine (NAC) for acetaminophen-induced hepatitis and consider for FHF
  
• Consider steroids for severe acute alcoholic hepatitis
  
• Ursodeoxycholic acid or cholestyramine for cholestasis-induced itching
  
• Paracentesis for tense ascites leading to respiratory compromise
  
• Antidotes and activated charcoal for select ingestions
  
• Postexposure prophylaxis (PEP):
  
  • HAV:
    
    • HAV IG 0.02 mL/kg IM within 2 wk of exposure
      
    • HAV vaccine 1 mL (peds: 0.5 mL) IM
      
  • HBV:
    
    • HBV IG 0.06 mL/kg IM within 7 days of exposure
      
    • HBV vaccine 1 mL (peds: 0.5 mL) IM
      
  • No effective immunoprophylaxis for HCV or HDV
    
  • HEV vaccine not available in US
    

• Cholestyramine: 4 g PO 2–4 times per day for pruritus
  
• Metoclopramide: 10 mg IV/IM q6–8h, 10–30 mg PO QID
  
• NAC 140 mg/kg IV loading dose
  
• Ondansetron 4 mg IV
  
• Prednisone 40 mg/d PO
  
• Thiamine: 100 mg (peds: 50 mg) IV/IM/PO:
  
  • Prior to glucose if malnutritioned
    
• Ursodeoxycholic acid: 3 mg/kg TID
  
• Vitamin K 10mg IV/PO
  

FOLLOW-UP

• Intractable vomiting, dehydration, or electrolyte imbalance not responding to ED treatment
  
• ICU and consider transfer to transplant center for FHF and acute hepatitis with evidence of significant liver dysfunction:
  
  • PT >50% of normal or INR >1.5
    
  • Bilirubin >20 mg/dL
    
  • Hypoglycemia
    
  • Albumin <2.5 g/dL
    
• Hepatic encephalopathy
  
• Pregnancy
  
• Immunocompromised host
  
• Possibility of toxic hepatitis
  
• Age >50
  

• Normalized electrolytes
  
• PO tolerance
  
• Mild hepatic impairment
  

• Hepatology, gastroenterology, and/or infectious disease follow-up for further serologic diagnosis and definitive treatment
  
• Alcoholics anonymous referral and social work referral for alcohol-related disease
  

• Strict personal hygiene instructions
  
• Avoid acetaminophen and alcohol
  
• Avoid prolonged physical exertion
  

• Acute hepatitis is often misdiagnosed as a nonspecific viral syndrome—screen with urinalysis or serum LFTs
  
• ED treatment is primarily supportive
  
• Ask detailed social and travel history
  
• Early transfer to transplant center for FHF
  
• Counsel patient on prevention – vaccinations and personal hygiene precautions
  
• Maintain high index of suspicion for AFLP and HELLP in pregnant patients with compatible symptoms
  

• Falade-Nwulia O, Seaberg EC, Rinaldo CR, et al. Comparative risk of liver-related mortality from chronic hepatitis B versus chronic hepatitis C virus infection.
  Clin Infect Dis.
  2012;55(4):507–513.
  
• Greenberger NJ, Blumberg RS, Burakoff R, eds.
  Current Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy
  . 2nd ed. McGraw-Hill; 2012.
  
• Hoofnagle JH, Nelson KE, Purcell RH. Hepatitis E.
  N Engl J Med.
  2012;367:1237–1244
  .
  
• Sundaram V, Shaikh OS. Acute liver failure: Current practice and recent advances.
  Gastroenterol Clin North Am.
  2011;40(3):523–539.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acetaminophen Poisoning
  
• Ascites
  
• Cirrhosis
  
• Hepatic Encephalopathy
  
• Hepatorenal Syndrome
  
• Jaundice
  
• Mushroom Poisoning
  

We wish to acknowledge the previous authors of this chapter for their contributions on this topic: Michael Schmidt, Amer Aldeen, and LucasRoseire.

CODES

• 070.1 Viral hepatitis A without mention of hepatic coma
  
• 070.30 Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta
  
• 573.3 Hepatitis, unspecified
  

BASICS

• Renal failure (RF) in patients with acute or chronic liver disease with no other identifiable cause of renal pathology.
  
• Hepatorenal syndrome (HRS) represents significant decline in renal perfusion due to severe liver disease:
  
  • Type I HRS:
    
    • Acute form with spontaneous RF in patients with liver disease
      
    • Rapidly progressive
      
    • Decrease in creatinine clearance (CrCl) by 50% or doubling of Cr in 2 wk (>2.5)
      
    • 90% mortality within 3 mo
      
    • Seen with acute liver failure or alcoholic hepatitis
      
    • Oliguric or anuric
      
  • Type II HRS:
    
    • Slow course of RF
      
    • Seen in patients with diuretic resistant ascites
      
    • Lower mortality rate than type I HRS
      
• Hallmarks of HRS:
  
  • Prerenal disease
    
  • Reversible renal vasoconstriction and mild systemic hypotension
    
  • Kidneys have normal histology and structure.
    
  • Lack of improvement in renal function after volume expansion
    
• Liver disease causes systemic vasodilation with decrease in arterial blood volume:
  
  • Reflex activation of sympathetic nervous system
    
  • Activation of rennin–angiotensin–aldosterone system (RAAS)
    
  • Stimulation of numerous vasoactive substances:
    
    • Nitric oxide
      
    • Prostacyclin
      
    • Atrial natriuretic peptide (ANP)
      
    • Arachidonic acid metabolites
      
    • Platelet-activating factor
      
    • Endothelins
      
    • Catecholamines
      
    • Angiotensin II
      
    • Thromboxane
      
• Action of vasoconstrictors prevails over vasodilator effects:
  
  • Renal hypoperfusion ensues due to renal cortical vasoconstriction.
    
  • Decrease in renal blood flow and glomerular filtration rates (GFRs)
    
• Decreased urine sodium excretion (U Na <10 mEq/day)
  
• Incidence of HRS:
  
  • 18% at 1st year, 39% at 5 yr
    
• Hyponatremia and high plasma renin levels are risk factors.
  

• Chronic liver disease, especially alcohol related (cirrhosis, severe alcoholic hepatitis)
  
• Fulminate hepatic failure
  
• Precipitating factors:
  
  • Decreased effective blood volume:
    
    • GI bleeding
      
    • Vigorous diuresis
      
    • Large-volume paracentesis
      
  • Use of nephrotoxic agent:
    
    • NSAIDs
      
    • Aminoglycoside
      
  • Sepsis:
    
    • Spontaneous bacterial peritonitis (SBP) leads to a 33% chance of developing RF during that year
      
    • Prophylaxis of SBP reduces the chance of developing acute RF