Cirrhotic patients may have stable liver function for long periods, but an acute insult in the presence of advanced fibrosis and decreased functional reserve can lead to hepatic decompensation. Patients with Acute on Chronic Liver Failure (ACLF) have a short-term mortality of 50%-90%.
About
- Chronic hepatocellular failure may occur due to decompensation.
- Typically arises in chronic liver disease, with or without an additional precipitant.
- Patients often present with ascites or encephalopathy.
- Generally, ACLF is not reversible unless a treatable precipitant is identified.
Aetiology of Chronic Liver Disease
- Alcoholic liver disease
- Autoimmune liver disease
- Non-alcoholic steatohepatitis
- Chronic Viral hepatitis (B and C); also CMV, EBV
- Primary Biliary Cirrhosis
- Wilson’s disease
- Haemochromatosis
- Primary Sclerosing Cholangitis
- Alpha-1 antitrypsin deficiency
- Cystic fibrosis
- Drugs: amiodarone, methotrexate, nitrofurantoin
- Type IV Glycogen storage disease
- Sarcoidosis
- Budd-Chiari syndrome
- Cardiac disease and right heart failure
- Idiopathic causes
Clinical Presentation of ACLF
- Signs to look for: jaundice, ascites, cachexia, variceal bleeding
- Assess for encephalopathy, spider naevi, pruritis
- Examine for bruising, splenomegaly, rashes, or arthritis
- Monitor for encephalopathy
| Grading of Encephalopathy |
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Precipitants
- Underlying disease progression and loss of liver function
- Hypoglycaemic episodes
- Sepsis: urinary tract, ascites, blood, CSF
- Medications: diuretics, sedatives, alcohol
- Constipation
- GI protein load from dietary input or GI bleed
- Paracentesis
- Paracetamol toxicity
Complications
- Ascites
- Hypoglycaemic episodes
- Spontaneous bacterial peritonitis (SBP)
- Hepatic encephalopathy
- Hepatorenal syndrome
- Hepatocellular carcinoma
Investigations
- Lab tests: FBC, U&E, glucose, phosphate, LFT, PT, AFP
- Coagulation: Check Prothrombin Time
- Infections: Blood cultures, MSSU, ascitic fluid analysis (Gram stain, WCC, culture), protein levels
- Viral Hepatitis Screening: Test for hepatitis B, C, autoantibody profile, paracetamol levels
- Imaging: Ultrasound of abdomen
Management
- ABC approach: Monitor to avoid hypoxaemia, hypotension, and hypoglycaemia. Admit under those with specialist skills.
- CT scan: If low GCS or new neurology, exclude SDH/ICH. Low GCS may indicate raised ICP or encephalopathy; consider ITU input.
- Lactulose: 30 ml orally TDS for early encephalopathy, titrated to 2-3 bowel movements daily. Use phosphate enemas if oral lactulose is unsuitable.
- Look for signs of sepsis and send blood, urine, and ascitic fluid for cell count and culture if encephalopathic.
- SBP: Ascitic tap should be done. If WBC >250/microlitre, start antibiotics.
- Manage medications: Check for sedatives, opiates, diuretics, alcohol withdrawal, or recent GI bleed.
- Electrolyte Management: Correct hyponatraemia with fluid restriction and any hypokalaemia, low phosphate, or low magnesium levels.
- Nutrition: Consider Pabrinex for any malnourishment or signs of B1 deficiency, especially in alcohol abuse.
- Imaging: Send for alpha-fetoprotein and perform an ultrasound if hepatoma is a concern.
- Monitor renal function, as patients are at risk for Hepatorenal syndrome.