Acute Liver Failure - Evaluation

Evaluation

All patients with clinical or laboratory evidence of moderate to severe acute hepatitis should have immediate measurement of prothrombin time and careful evaluation of mental status. If the prothrombin time is prolonged by ≈ 4–6 seconds or more (INR ≥ 1.5), and there is any evidence of altered sensorium, the diagnosis of ALF should be strongly suspected, and hospital admission is mandatory. Initial laboratory examination must be extensive in order to evaluate both the aetiology and severity.

Initial laboratory analysis

• Prothrombin time/INR
• Complete blood count
• Chemistries
  • Liver function test: AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin
  • Creatinine, urea/blood urea nitrogen, sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate
  • Glucose
  • Amylase and lipase
• Arterial blood gas, lactate
• Blood type and screen
• Paracetamol (acetaminophen) level, toxicology screen
• Viral hepatitis serologies: anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HCV
• Autoimmune markers: ANA, ASMA, LKMA, immunoglobulin levels
• Ceruloplasmin level (when Wilson's disease suspected)
• Pregnancy test (females)
• Ammonia (arterial if possible)
• HIV status (has implication for transplantation)

History taking should include careful review of possible exposures to viral infection and drugs or other toxins. From history and clinical examination, possibility of underlying chronic disease should be ruled out as it may require different management.

A liver biopsy done via the transjugular route because of coagulopathy is not usually necessary, other than in occasional malignancies. As the evaluation continues, several important decisions have to be made; such as whether to admit the patient to an ICU, or whether to transfer the patient to a transplant facility. Consultation with the transplant centre as early as possible is critical due to possibility of rapid progression of ALF.