A 35-year-old female with no known previous medical history presents to the emergency department with a decreased conscious level.

The following results are obtained

Venous Biochemistry

Parameter

Patient Value

Normal Adult Range

Sodium

144 mmol/L

135 – 145

Potassium

4.0 mmol/L

3.5 – 4.5

Chloride

100 mmol/L

95

105

Bicarbonate

14 mmol/L*

22

26

Glucose

1.1mmol/L*

3.5 – 6.1

Urea

2.7 mmol/L

2.9 – 8.2

Creatinine

120 μmol/L

70

120

Albumin

46 g/L

35

55

Total bilirubin

90 μmol/L*

< 20

Alkaline phosphatase (ALP)

131 U/L*

36

92

Aspartate aminotransferase (AST)

2450 U/L*

< 40

Gamma glutamyl transferase (GGT)

50 U/L*

< 30

Alanine aminotransferase  (ALT)

2750 U/L*

< 35

Coagulation Tests

Parameter

Patient Value

Normal Adult Range

PT

45 sec*

12

16

APTT

46 sec*

25.0

– 37.0

Fibrinogen

0.2 g/ L*

2.20

– 4.30

a)  Give one diagnosis which will explain the clinical and laboratory findings.    (10% marks)
b)  List six possible aetiologies.                    (20% marks)

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College Answer

a)    

  • Acute liver failure

b)

  • Toxins – paracetamol, alcohol, mushrooms. Viral hepatitis – hep A,B,C,D,E, EBV,CMV
  • Idiosyncratic drug reaction
  • Ischaemic hepatitis due to shock – cardiogenic, septic. Acute fatty liver of pregnancy.
  • Congenital/genetic - Wilson’s disease. Hyperthermia - Heat stroke.
  • Autoimmune hepatitis. Budd-chiari syndrome.
  • Malignant hepatic infiltrations – breast cancer, lung cancer, melanoma, lymphoma, myeloma.

Discussion

Well, you can't call it "acute liver failure" or "hyper-acute" or subacute" because these have specific time intervals as definitions. All you can really say is that there is liver failure. The college gives malingant infiltration as a differential, which gives one the impression that they would be willing to consider the more insidious causes of liver damage.

Possible categories of the causes:

Vascular:

  • Right heart failure
  • Hepatic arterial ischaemia (eg. due to either global ischaemia, or due to an embolic event)
  • Hepatic venous insufficiency (Budd-Chiari syndrome)
  • Veno-occlusive disease (eg. post bone marrow transplant)

Infectious:

  • Hepatitis A, B and C
  • Hepres simlex
  • Cytomegalovirus
  • Varicella

Neoplastic:

  • Colonic carcinoma metastases
  • Hepatocellular carcinoma
  • Lymphoma

Drug-induced:

  • Paracetamol
  • Alcohol
  • Kava-kava
  • Tuberculosis antibiotics
  • Amanita phalloides mushroom
  • Cocaine (by ischaemia)
  • Solvents: xylene, chloroform, trichloroethylene, carbon tetrachloride
  • MDMA

Idiopathic: idiosyncratic drug reactions:

  • Anticonvulsants
  • NSAIDs
  • Aspirin in children (Reye's syndrome)

Congenital:

  • Wilson's disease

Autoimmune:

  • Haemophagocytic syndrome
  • Vasculitic hepatitis

Traumatic:

  • Crush injury to the liver
  • Capsular hematoma
  • Disruption of hepatic vessels
  • Hyperthermia-induced liver injury

Endocrine/metabolic:

  • Acute fatty liver of pregnancy
  • HELLP syndrome
  • Pregnancy-associated liver rupture