Ep 148 Liver Emergencies: Acute Liver Failure, Hepatic Encephalopathy, Hepatorenal Syndrome, Liver Test Interpretation & Drugs to Avoid

For such a large organ, EM physicians spend proportionally little time thinking about the liver. Sure, we’re often in the neighborhood (whether it be doing a FAST or diagnosing biliary disease), but the liver really doesn’t get the credit it's due. Nonetheless, from time to time, whether it be the acute liver failure patient gushing from a varix whose INR is greater than his shoe size, or the confused hepatic encephalopathy patient levitating off the bed using nothing but asterixis, there are definitely times where the middle child of the abdomen steals the show. In this podcast on liver emergencies and acute liver failure with Dr.Walter Himmel and Dr.Brian Steinhart, we answer questions such as: What are the most important causes of acute liver failure that we need to identify in the ED so we can initiate timely treatment? What are some of the common medications we use in the ED that we should avoid in the liver patient? How should we approach the interpretation of liver enzymes and liver function tests? What are the key management steps in treating acute liver and hepatorenal syndrome? Why do liver failure patients become hypoglycemic and how should hypoglycemia in these patients be treated in the ED? How do we diagnose hepatorenal syndrome in the ED? How can the MELD score help us manage liver patients? What are the indications for IV albumin? What is the role of an ammonia level in the diagnosis of hepatic encephalopathy? Is polyethylene glycol a better alternative to lactulose for treating hepatic encephalopathy? and much more... Podcast production, sound design & editing by Anton Helman. Voice editing by Raymond Cho. Written Summary and blog post by Jennifer He and Anton Helman, November, 2020 Cite this podcast as: Helman, A. Himmel, W. Steinhart, B. Episode 148 Liver Emergencies: Acute Liver Failure, Hepatic Encephalopathy, Hepatorenal Syndrome, Liver Test Interpretation & Drugs to Avoid. Emergency Medicine Cases. November, 2020. https://emergencymedicinecases.com/liver-emergencies-acute-liver-failure-hepatic-encephalopathy-hepatorenal-syndrome-liver-test-interpretation. Accessed [date] Go to part 2 of this 2-part podcast on liver emergencies Acute Liver Failure Patients with acute liver failure in the ED may progress to multiorgan failure unless treatment is initiated early. The cytokine release in liver failure and necrosis kicks off a systemic inflammatory response, causing vasodilation and hypoperfusion. Patients with liver cirrhosis have an increased susceptibility to bacterial infections due to a compromised immune system, portal hypertension due increased portal venous flow and hepatic resistance, thrombosis due to complex alterations in the coagulation factors and hypoalbuminemia, and bleeding due to portal hypertension as well as complex alterations in the coagulation factors . Liver patients may have decreased gluconeogenesis (leading to hypoglycemia), decreased lactate clearance (leading to metabolic acidosis) and decreased ammonia clearance (leading to hyperammonemia). All of these need to be considered in the ED management of patients with acute liver failure. Triggers for decompensation in patients with liver disease: Search carefully for infections Infections are a common high risk trigger for acute liver failure in patients with chronic liver disease and may present in a subtle manner, similar to the immunocompromised patient. It is therefore incumbent upon the emergency physician to conduct a thorough search for underlying infection in the sick liver patient. Pneumonia, ARDS and sepsis are the most common diagnoses of ESLD patients admitted to ICU.