Fulminant hepatic failure

Fulminant hepatic failure is a devastating complication of viral hepatitis, hepatotoxic exposures, and a variety of other acute liver diseases. Although this syndrome is associated with high mortality, liver transplantation can be life saving. This article discusses the medical management of fulminant hepatic failure and emphasizes complications, determinants of survival, and patient selection for liver transplantation.

Acute lung injury in fulminant hepatic failure following paracetamol poisoning

BACKGROUND

There is little information on the incidence of acute lung injury or changes in the pulmonary circulation in acute liver failure. The aim of this study was to record the incidence of acute lung injury in fulminant hepatic failure caused by paracetamol poisoning, to document the associated pulmonary circulatory changes, and to assess the impact of lung injury on patient outcome.

METHODS

The degree of lung injury was retrospectively assessed by a standard scoring system (modified from Murray) in all patients with fulminant hepatic failure caused by paracetamol poisoning, admitted to the intensive care unit over a one year period. The severity of liver failure and illness, other organ system failure, and patient outcome were also analysed.

RESULTS

Twenty four patients with paracetamol-induced liver failure were admitted and nine developed lung injury of whom eight (33%) had severe injury (Murray score > 2.5). In two patients hypoxaemia contributed to death. Patients with lung injury had higher median encephalopathy grades (4 v 2 in the non-injured group) and APACHE II scores (29 v 16). Circulatory failure, requiring vasoconstrictor support, occurred in all patients with lung injury but in only 40% of those without. Cerebral oedema, as detected by abnormal rises in intracranial pressure, also occurred in all patients with lung injury but in only 27% of the non-injured patients. The incidence of renal failure requiring renal replacement therapy was similar in both groups (67% and 47%). Pulmonary artery occlusion pressures were normal in the lung injury group. Cardiac output was high (median 11.2 1/min), systemic vascular resistance low (median 503 dynes/s/cm-5), and pulmonary vascular resistance low (median 70 dynes/s/cm-5), but not significantly different from the group without lung injury. Mortality was much higher in the lung injury group than in the non-injured group (89% v 13%).

CONCLUSIONS

Acute lung injury was common in patients with paracetamol-induced fulminant hepatic failure and was associated with systemic circulatory failure and cerebral oedema. The development of acute lung injury was associated with high mortality.

A non-invasive method for evaluating cirrhotic portal hypertension by administration of 99mTc-MIBI per rectum

A study was performed to evaluate radio-isotopic imaging using technetium-99m hexakis 2-methoxyisobutyl isonitrile administered per rectum to assess portal collateral circulation. The heart-liver ratios (H/L; mean +/- standard deviation) in 15 controls, 13 cases of histologically confirmed viral hepatitis and 57 cirrhosis patients were 0.27 +/- 0.11, 0.43 +/- 0.14 and 1.00 +/- 0.28, respectively (P < 0.001). Among the cirrhosis patients those with the Child-Pugh classification A, B and C had H/L of 0.56 +/- 0.14, 1.00 +/- 0.20 and 1.19 +/- 0.26, respectively (P < 0.001). A high value of H/L was associated with a high risk of hepatic encephalopathy (1.25 +/- 0.17, P < 0.01) and oesophageal varices (1.02 +/- 0.20, P < 0.01). There were associations between H/L and serum bilirubin (P < 0.01), albumin (P < 0.05) and prothrombin time (P < 0.05). The results also showed a good correlation between H/L and portal vein pressure measured during operation in 13 patients (P < 0.001, r = 0.87). The regression equation: y = 6.77 + 32.5 H/L, allowed portal vein pressure to be estimated. The prognostic value of the test was supported by the fact that good correlations were observed between the H/L ratio and widely accepted prognostic classification (Child-Pugh). It is suggested that this new method could be a reliable non-invasive way to give an indication of the degree of portasystemic shunting to evaluate the prognosis and to follow up the effects of medications for reducing portal hypertension in patients with cirrhotic portal hypertension.

Clinical and radiologic features of cerebral edema in fulminant hepatic failure

OBJECTIVE

To describe a series of consecutive patients with fulminant hepatic failure (FHF) and to present a new classification system for brain edema, an important cause of mortality in such patients.

DESIGN

We reviewed 22 computed tomographic (CT) scans of the brain in 12 patients with FHF and classified the severity of cerebral edema by using predefined criteria.

RESULTS

No cerebral edema was detected on CT scans in four patients with stage 1 or 2 hepatic encephalopathy at the time of admission, but it was noted in seven of eight patients with stage 3 or 4 hepatic encephalopathy. The severity of brain edema on CT scans was significantly correlated (P < 0.001) with the stage of hepatic encephalopathy. Three of the four patients who had stage 1 or 2 hepatic encephalopathy at the time of initial assessment ultimately had a good outcome. Of seven patients with stage 3 encephalopathy, two had rapid deterioration to brain death, three died of nonneurologic causes, and two had a good outcome after liver transplantation. One patient with stage 4 hepatic encephalopathy died, and autopsy showed cerebral edema.

CONCLUSION

Stage 3 or 4 hepatic encephalopathy is associated with cerebral edema that can be detected on CT scans. The clinical and radiologic signs of cerebral edema in patients who have progression to stage 3 hepatic encephalopathy can be reversed with conventional treatment of increased intracranial pressure. Whether early recognition and treatment of cerebral edema result in increased survival of patients with FHF remains to be determined.

Increased signals seen in globus pallidus in T1-weighted magnetic resonance imaging in cirrhotics are not suggestive of chronic hepatic encephalopathy

Increased, symmetrical signals of varying intensity in the globus pallidi on T1-weighted (T1W) images, without corresponding signals on T2-weighted (T2W) images, have been reported previously in chronic hepatic failure. It has been suggested that these signals are characteristic of chronic hepatic encephalopathy. To test this hypothesis, we evaluated the relationship of magnetic resonance imaging (MRI) abnormalities with ammonia, albumin, bilirubin, prothrombin time, ascites, clinical encephalopathy, and neuropsychological tests in 46 patients (16 with alcohol-induced cirrhosis and 30 with non-alcohol-induced cirrhosis). T1W signal and cortical atrophy were graded by a neuroradiologist in a blinded fashion. Eleven patients had no T1W signal, 18 had minimal T1W signal, and 17 had high T1W signal. Twenty-five patients had no cortical atrophy, 14 had mild atrophy, and 7 had moderate atrophy. Cortical atrophy was noted more commonly in patients with alcohol-induced liver disease. The neuropsychological tests correlated significantly with albumin, prothrombin time, Child-Pugh's score, clinical encephalopathy, and ammonia. T1W signal and cortical atrophy did not correlate with the neuropsychological tests, clinical encephalopathy, ascites, albumin, prothrombin time, ammonia, or Child-Pugh's score. Patients with high T1W signal showed significant correlation with bilirubin (P < .005). This study suggests that globus pallidus signal in T1W images observed in liver disease are not indicators of chronic hepatic encephalopathy as previously assumed.

[Lactitol suppresses the disturbance of consciousness caused by experimentally induced hepatic encephalopathy in rats: an EEG study]

Electroencephalographic (EEG) studies were conducted to demonstrate the ameliorating effects of lactitol and its reference drug lactulose on the disturbance of consciousness caused by severe hepatic encephalopathy in rats permanently implanted with cortical electrodes. A novel experimental animal model of combined-type human hepatic encephalopathy was prepared by portacaval shunting followed by a single treatment with dimethylnitrosamine (30 mg/kg, i.p.). Lactitol or lactulose was orally administered twice a day for seven days and once on the morning of the eighth day. Ammonium acetate (500 mg/kg) was injected into the cecum 4 hr after the final administration of the drug. In control animals not treated with either drug, but in which hepatic encephalopathy had been induced, ammonium acetate induced a comatose state defined by a loss of the righting reflex accompanied by slowing or flattening of the cortical EEG. In control animals, significant increases in delta (1-3 Hz)-activity and significant decreases in beta (13-25 Hz)-activity during coma were detected by means of EEG power spectral analysis. Lactitol at doses of 3 g/kg/day or higher or lactulose at 6 g/kg/day significantly suppressed these EEG changes. Both drugs also suppressed in a dose-dependent manner the loss of the righting reflex. Lactitol may therefore be useful for ameliorating the disturbance of consciousness in patients with hepatic encephalopathy.

Alterations of [3H]8-OH-DPAT and [3H]ketanserin binding sites in autopsied brain tissue from cirrhotic patients with hepatic encephalopathy

Affinities and densities of binding sites for the 5HT1A receptor ligand [3H]8-hydroxy(di-n-propylamino)tetralin ([3H]8-OH-DPAT) and the 5HT2 receptor ligand [3H]ketanserin were measured using a rapid filtration assay in crude membrane preparations from frontal cortex and hippocampus of nine cirrhotic patients who died in hepatic encephalopathy and from an equal number of age-matched subjects free from hepatic, neurological or psychiatric disorders. Binding site densities (Bmax) obtained by Scatchard analysis of saturation binding isotherms for [3H]8-OH-DPAT were decreased in frontal cortex (by 56%, P < 0.05) and hippocampus (by 30%, P < 0.05). [3H]ketanserin binding sites were concomitantly increased (by 55%, P < 0.05) in hippocampus of cirrhotic patients. Ligand binding affinities were within normal ranges in all cases. Previous reports have described the accumulation of the 5HT metabolite 5-hydroxyindoleacetic acid and increased activities of the 5HT-metabolizing enzyme MAOA in this same material from patients with hepatic encephalopathy. Taken together, these findings suggest that alterations of serotoninergic function in brain could be responsible for some of the neuropsychiatric symptoms of hepatic encephalopathy observed in humans with chronic liver disease.

Acute cerebral edema as part of the syndrome of hepatic encephalopathy in an individual with chronic liver disease: a case report

An unusual case of acute cerebral edema as part of the syndrome of portal systemic encephalopathy in an individual with established chronic liver disease is reported. Several episodes of edema occurred with clinically important increases in the blood ammonia level.

Toxic effects of intravenous and oral prostaglandin E therapy in patients with liver disease

BACKGROUND

Prostaglandins are cytoprotective agents that have been shown to benefit patients with a variety of acute and chronic liver diseases. Few data exist on the frequency of adverse effects of prostaglandins in these patients.

METHODS

We retrospectively studied 105 patients with liver disease who were treated with either intravenous (i.v.) or oral prostaglandin E (PGE). Forty-four patients with primary nonfunction after liver transplantation and 36 patients with fulminant hepatic failure received i.v. PGE1 for 4.5 +/- 2.6 and 12.6 +/- 10.9 days, respectively. Twenty-five patients with recurrent hepatitis B viral infection after liver transplantation received oral PGE1 for 105 +/- 94 days or PGE2 for 464 +/- 399 days.

RESULTS

Twenty-six of 80 patients (33%) receiving i.v. PGE1 developed gastrointestinal and/or cardiovascular side effects and 8% developed arthritis. Twenty-three of 25 patients (92%) who received high-dose oral PGE1 or PGE2 incurred arthritis and/or gastrointestinal adverse effects. Twenty-five patients received prolonged PGE therapy (oral > 60 days; i.v. > 28 days). Of this group, 23 (92%) developed clubbing and cortical hyperostosis resembling hypertrophic osteoarthropathy. All adverse effects were dose related and resolved with reduction or cessation of therapy.

CONCLUSION

PGE therapy resulted in a wide spectrum of multisystem adverse effects which were reversible with reduction or cessation of therapy. Although the administration of PGE was safe and generally well tolerated, close medical supervision is necessary to avoid serious side effects.

Typhoid fever associated with severe hepatitis

While typhoid is quite common in our environment, presentation in association with severe hepatitis and hepatic encephalopathy is uncommon. The case of a 14 year old male with typhoid who presented with jaundice and severe hepatitis with encephalopathy is presented. The first symptoms occurred one week before presentation. The clinical features and laboratory investigations confirmed typhoid fever. The associated severe hepatitis could have been related to a direct liver involvement by Salmonella typhi, drug toxicity or hepatitis B infection from previous indiscriminate parenteral drugs. The specific cause of the hepatitis could not be confirmed. The patient is presented to illustrate a rare association and possible complication of typhoid fever, inappropriate self and other medication in the place of proper hospital presentation and assessment and the diagnostic difficulties confronting many centres in the developing environment.

Cerebral blood flow and metabolism in fulminant liver failure

Fulminant liver failure is a syndrome that is frequently complicated by cerebral edema and increased intracranial pressure. Cerebral blood flow has been reported as high in some studies but low in others. This study undertook to measure cerebral blood flow and cerebral metabolic rate for oxygen in 30 patients with fulminant liver failure in grade 4 encephalopathy and to assess these parameters after intervention with hyperventilation and infusions of mannitol, epoprostenol and acetylcysteine. Cerebral blood flow varied widely, from 14 to 71 ml/100 gm/min (normal range, widely, from 14 to 71 ml/100 gm/min (normal range, 41 to 66), whereas the cerebral metabolic rate for oxygen was low in all patients, 0.16 to 2.03 ml/100 gm/min (normal range, 3.12 to 3.96). Twenty-one of the 30 patients had evidence of anaerobic metabolism with cerebral lactate production. Hyperventilation resulted in a significant decrease in both cerebral blood flow (median, 36 to 28 ml/100 gm/min) and cerebral metabolic rate for oxygen (median, 0.92 to 0.65 ml/100 gm/min); mannitol and acetylcysteine infusions resulted in significant increases in both of these parameters. Prostaglandin I2 infusion did not significantly after cerebral blood flow, but there was a significant increase in cerebral metabolic rate for oxygen. The depressed cerebral metabolic rate for oxygen in patients with fulminant liver failure is inappropriate to metabolic requirements, as demonstrated by both cerebral lactate production and the increase in cerebral oxygen consumption after improvement in cerebral blood flow. Mannitol infusion should remain the main treatment of the cerebral complications of fulminant liver failure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Multiple organ failure syndrome in fulminant hepatic failure]

BACKGROUND

in fulminant hepatic failure, different organs systems become involved and a multiple systems organic failure may ensure.

AIM

to perform a retrospective analysis of patients with fulminant hepatic failure admitted to UC Hospital Intensive Care Unit.

PATIENTS AND METHODS

the charts of fourteen patients (8 male) were analyzed. Multiple systems organic failure was defined as the presence of 2 or more organic dysfunctions. The evolution and mortality of these patients was analyzed.

RESULTS

patient's ages ranged from 30 to 74 years. The etiology of hepatic failure was B hepatitis in 4, non A non B hepatitis in 5, acute fatty liver of pregnancy in 3 and use of halothane and HIN in 2. ICU stay ranged from 1 to 44 days and 2 patients survived (one with drug induced liver failure and one with acute fatty live of pregnancy). Mean prothrombin time was 19 +/- 9.5%, total bilirrubin was 24 +/- 8.9 mg/dl and 12 patients reached grade IV encephalopathy. Mean admission APACHE II score was 21.5 +/- 6. Twelve patients developed multiple systems organic failure, that appeared 1.5 days after or was already present at ICU admission; it lasted a mean of 2.5 days and all these 12 patients died. Neurologic involvement occurred in 13 patients, renal in 10, cardiovascular in 9, respiratory in 5 and hematological involvement in 1.

CONCLUSIONS

multiple systems organic failure is frequent in fulminant hepatic failure and is associated with a high mortality.

Recovery despite impaired cerebral perfusion in fulminant hepatic failure

We report 4 patients with fulminant hepatic failure who developed prolonged intracranial hypertension (> 35 mm Hg for 24-38 h) that was refractory to standard therapy and associated with impaired cerebral perfusion pressure (< 50 mm Hg for 2-72 h). All survived with complete neurological recovery. Refractory elevation of intracranial pressure and reduced cerebral perfusion pressure are generally thought to contra-indicate liver transplantation in hepatic failure and are indications to withdraw support. Our observations challenge this concept.

Duplicate prealbumin bands in urine. Association with hepatorenal failure

By electrophoresis, prealbumin is seen as a discrete band anodic to the albumin fraction. Cases of duplicate bands in the prealbumin region have been described previously in serum, cerebrospinal fluid, and urine, and have had an association with varied clinical entities. The authors describe a novel association of severe hepatic and renal failure with the presence of prominent duplicate prealbumin bands in urine.

Hepatic encephalopathy presenting as delirium and mania. The possible role of bilirubin

The case of a woman who suffered from hepatic encephalopathy is described. The psychiatric symptoms presented first as a delirium, changing into a manic syndrome. As the neurotoxic direct fraction of bilirubin was greater than 100 times normal, increasing and decreasing in a parallel fashion with the psychiatric symptoms, direct bilirubin is assumed to play a role in the pathogenesis of this case. This is discussed in the context of bilirubin encephalopathy, very seldom diagnosed in adults.