A 26 year old female presents to the Emergency Department having been found at home confused and jaundiced by her GP.
Her GCS is E3V5M5
She has a temperature of 38 ˚C, BP 90/60, HR 90 and SpO2 94% on 4 litres/min O2.
Her plasma biochemistry is as follows:
|
Test |
Value |
Normal Range |
|
Sodium |
137 mmol/L |
(135 – 145) |
|
Potassium |
4.1 mmol/L |
(3.5 – 5.0) |
|
Total bilirubin* |
200 micromol/L |
(0 – 25) |
|
AST* |
4000 U/L |
(<40) |
|
GGT* |
500 U/L |
(<40) |
|
ALT* |
3000 U/L |
(<40) |
|
Urea |
4.2 mmol/L |
(4 – 6) |
Coagulation profile:
|
Test |
Value |
Normal Range |
|
INR* |
2.6 |
(0.8 – 1.2) |
a) Based on the above information, what do you think this woman is suffering from?
b) List 5 important aetiologies which could result in this presentation.
c) List 4 important complications (apart from respiratory failure) she is at risk of developing.
d) List 4 reasons why this woman might progress to developing respiratory failure.
a) Based on the above information, what do you think this woman is suffering from?
Acute liver failure (without more detail it is hard to say, hyperacute, acute, subacute or chronic)
b) List 5 important aetiologies which could result in this presentation.
• Sepsis
• Viral hepatitis – Hep B/C/D, CMV/EBV
• Drug induced
• Poisoning
• Miscellaneous (wilson’s disease, acute fatty liver of pregnancy, ischaemic necrosis, Budd-Chiari, complications of hepatic surgery)
• Idiopathic
• Pregnancy related
c) List 4 important complications (apart from respiratory failure) she is at risk of developing.
• Cerebral oedema and herniation
• Coagulopathy
• GI bleed
• Sepsis
• Renal failure
d) List 4 reasons why this woman might progress to developing respiratory failure.
• Impaired ventilation because of coma
• Pleural effusions
• ARDS
• Intra-pulmonary shunts
• Aspiration pneumonia
• Sepsis- pulmonary or extrapulmonary
a) Based on the above information, what do you think this woman is suffering from?
With the transaminases in their thousands, a raised bilirubin, coagulopathy and fever, one might assume that this lady has some sort of acute hepatitis. As the college rightly points out, "acute hepatic failure" is the only description one can make without any further history.
b) List 5 important aetiologies which could result in this presentation.
c) List 4 important complications (apart from respiratory failure) she is at risk of developing.
There is a brilliant article on this subject which outlines all the possible and impossible complications of acute hepatic failure. I will summarise their Panel 1:
Complications of acute liver failure
d) List 4 reasons why this woman might progress to developing respiratory failure.
This answer calls for differentials of respiratory failure in a semiconscious shocked woman with fever.
Bernal, William, et al. "Acute liver failure." The Lancet 376.9736 (2010): 190-201.
Fallon, Michael B., and Gary A. Abrams. "Pulmonary dysfunction in chronic liver disease." Hepatology 32.4 (2000): 859-865.