| ⚠️ Acute Liver Failure |
- Jaundice, coagulopathy and hepatic encephalopathy.
- Nausea, vomiting, malaise, right upper quadrant pain.
- Confusion, agitation, drowsiness or coma.
- Hypoglycaemia, lactic acidosis, renal failure or cerebral oedema may occur.
- Common UK cause: paracetamol toxicity; also viral hepatitis, drug-induced liver injury, autoimmune hepatitis, Wilson disease and pregnancy-related liver disease.
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- LFTs, bilirubin, albumin, INR/PT, glucose, lactate, U&E, phosphate, ABG/VBG.
- Paracetamol level in all unexplained acute hepatitis/ALF.
- Viral hepatitis screen: HAV, HBV, HCV, HEV; consider HSV/EBV/CMV depending on context.
- Autoimmune markers and IgG.
- Ultrasound liver with Doppler to assess vascular/biliary causes.
- Pregnancy test where relevant.
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- Medical emergency: discuss early with hepatology/liver transplant centre.
- Admit to HDU/ICU if encephalopathy, rising INR, acidosis, renal failure or hypoglycaemia.
- Give N-acetylcysteine for paracetamol toxicity; it may also be considered in selected non-paracetamol ALF under specialist guidance.
- Frequent glucose monitoring and IV dextrose if needed.
- Treat cause: antivirals, steroids for selected autoimmune disease, delivery for pregnancy-related disease, toxin-specific therapy where indicated.
- Manage cerebral oedema, sepsis, renal failure and coagulopathy with specialist/ICU input.
- Do not correct INR routinely with FFP unless bleeding or procedure planned, because INR is prognostic.
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| 🩸 Variceal Haemorrhage |
- Haematemesis, melaena or haematochezia with shock.
- History of cirrhosis, portal hypertension, ascites or known varices.
- Tachycardia, hypotension, syncope or encephalopathy.
- Bleeding may precipitate infection, renal failure and encephalopathy.
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- FBC, U&E, LFT, INR/clotting, fibrinogen, lactate.
- Group and save/crossmatch.
- Endoscopy after resuscitation confirms source and allows banding/glue therapy.
- Assess severity: Child-Pugh/MELD where specialist team involved.
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- ABCDE, two large-bore IV lines, cautious resuscitation and blood transfusion as required.
- Restrictive transfusion strategy is often used unless massive bleeding/instability dictates otherwise.
- Start terlipressin or local vasoactive agent as soon as variceal bleeding is suspected, unless contraindicated.
- Give IV antibiotics because infection risk is high in cirrhotic GI bleeding.
- Urgent endoscopy for band ligation or other endoscopic haemostasis.
- Balloon tamponade or covered oesophageal stent may be a bridge in uncontrolled bleeding.
- Consider early/rescue TIPS for refractory or high-risk bleeding.
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| 🦠 Spontaneous Bacterial Peritonitis |
- Cirrhosis with ascites plus fever, abdominal pain or tenderness.
- May present subtly with encephalopathy, AKI, hypotension or worsening ascites.
- Can occur without marked abdominal signs.
- High risk of sepsis and hepatorenal syndrome.
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- Diagnostic paracentesis before antibiotics if this does not delay treatment.
- Ascitic neutrophil count ≥250 cells/mm³ confirms SBP.
- Ascitic culture, ideally inoculated into blood culture bottles at bedside.
- Blood cultures, FBC, U&E, LFT, INR, CRP, lactate if septic.
- Check renal function to guide albumin need and prognosis.
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- Start IV antibiotics according to local policy, commonly a third-generation cephalosporin where appropriate.
- Give IV albumin in selected/high-risk patients to reduce renal dysfunction risk.
- Stop diuretics temporarily if AKI, sepsis or hypotension.
- Repeat paracentesis if poor response or diagnostic uncertainty.
- Secondary prophylaxis after recovery, guided by hepatology/local policy.
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| 🧠 Hepatic Encephalopathy |
- Sleep reversal, confusion, agitation, drowsiness or coma.
- Asterixis may be present.
- Often occurs in cirrhosis or after portosystemic shunting.
- Triggers: infection, GI bleeding, constipation, dehydration, hypokalaemia, hyponatraemia, AKI, sedatives/opioids, excess diuretics.
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- Clinical diagnosis; ammonia level is not required and correlates poorly with severity.
- Search for precipitant: cultures, CXR, urinalysis, diagnostic tap if ascites, stool/bleeding assessment.
- U&E, glucose, LFT, INR, FBC, CRP.
- Consider CT head if focal neurology, trauma, first presentation or diagnostic uncertainty.
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- ABCDE; protect airway if severe coma/vomiting/aspiration risk.
- Identify and treat precipitating cause.
- Lactulose titrated to 2–3 soft stools/day.
- Rifaximin may be added for recurrent or persistent encephalopathy under specialist guidance.
- Correct dehydration/electrolytes and stop sedatives, opioids and unnecessary diuretics.
- Treat GI bleeding, infection or constipation promptly.
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| 🫘 Hepatorenal Syndrome / AKI in Cirrhosis |
- Cirrhosis with ascites and rising creatinine.
- Oliguria, fatigue, hypotension or hyponatraemia.
- Often triggered by SBP, GI bleeding, over-diuresis, dehydration or nephrotoxins.
- HRS is a diagnosis of exclusion after other causes of AKI are considered.
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- U&E/creatinine trend and urine output.
- Urinalysis: bland urine supports HRS but does not prove it.
- Renal ultrasound to exclude obstruction if appropriate.
- Diagnostic paracentesis to exclude SBP in ascites.
- Review nephrotoxins and diuretic exposure.
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- Stop diuretics, NSAIDs and nephrotoxins.
- Treat infection, bleeding or hypovolaemia.
- IV albumin volume expansion under hepatology guidance.
- Vasoconstrictor therapy such as terlipressin may be used with albumin in HRS-AKI under specialist supervision.
- Discuss with hepatology/transplant centre; liver transplantation is definitive for eligible patients.
- Renal replacement therapy may be bridge/support in selected cases.
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| 🟡 Acute Cholestasis / Choledocholithiasis / Cholangitis |
- RUQ pain, jaundice, dark urine, pale stools and pruritus.
- Charcot triad: fever, jaundice and RUQ pain suggests cholangitis.
- Reynolds pentad: add hypotension and confusion - severe cholangitis/sepsis.
- History of gallstones or biliary intervention may be present.
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- LFTs: cholestatic pattern with raised bilirubin, ALP and GGT.
- FBC, CRP, U&E, clotting, lactate and blood cultures if febrile/septic.
- Ultrasound for bile duct dilatation/gallstones.
- MRCP or CT if diagnosis unclear.
- ERCP is diagnostic and therapeutic when drainage needed.
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- If cholangitis: sepsis pathway, IV fluids and IV antibiotics.
- Urgent gastroenterology/HPB review.
- ERCP for biliary drainage/source control, especially if severe, obstructed or not improving.
- Cholecystectomy planning if gallstones are the underlying cause and patient suitable.
- Monitor for pancreatitis, sepsis and AKI.
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| 🍷 Severe Alcohol-Related Hepatitis |
- Recent heavy alcohol use with jaundice, anorexia, fever and RUQ pain.
- Tender hepatomegaly, ascites or encephalopathy may occur.
- Systemic inflammation with high bilirubin and coagulopathy.
- Commonly coexists with infection, GI bleeding, pancreatitis or renal dysfunction.
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- LFTs: AST usually >ALT, often both <300–500 IU/L; bilirubin raised.
- INR/PT, albumin, FBC, U&E, CRP, cultures and diagnostic tap if ascites.
- Ultrasound to assess biliary obstruction and cirrhosis features.
- Severity scores: Maddrey discriminant function, MELD, Glasgow alcoholic hepatitis score; Lille score after treatment start if steroids used.
- Exclude other causes of acute jaundice/hepatitis.
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- Alcohol abstinence support and alcohol liaison/addiction input.
- Nutritional support, thiamine and vitamin replacement.
- Treat infection, GI bleeding, renal failure and withdrawal.
- Prednisolone may be considered in selected severe cases after excluding contraindications such as uncontrolled sepsis, GI bleeding or severe renal failure.
- Pentoxifylline is no longer routinely recommended in many modern pathways due to lack of clear benefit.
- Early hepatology input; consider transplant discussion in carefully selected severe cases.
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| 🤰 Acute Fatty Liver of Pregnancy |
- Usually third trimester or early postpartum.
- Nausea, vomiting, abdominal/RUQ pain, malaise and jaundice.
- May progress to hypoglycaemia, encephalopathy, coagulopathy, renal failure and DIC.
- Can overlap with pre-eclampsia/HELLP.
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- LFTs, bilirubin, INR/PT, APTT, fibrinogen.
- Glucose: hypoglycaemia is a key clue.
- U&E/creatinine, uric acid, FBC/platelets, ammonia if encephalopathy.
- Assess for HELLP, viral hepatitis, gallstones and other causes.
- Ultrasound may be normal and does not exclude AFLP.
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- Obstetric and hepatology emergency.
- Stabilise mother first: glucose, fluids, blood products and correction of coagulopathy as needed.
- Plan prompt delivery after maternal stabilisation with senior obstetric/anaesthetic/neonatal input.
- HDU/ICU care if organ failure, severe coagulopathy, hypoglycaemia or encephalopathy.
- Monitor closely postpartum until liver, renal and coagulation parameters recover.
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| 🩸 Budd–Chiari Syndrome |
- Hepatic venous outflow obstruction.
- Abdominal pain, hepatomegaly and ascites.
- May present acutely with liver failure or chronically with portal hypertension.
- Risk factors: myeloproliferative neoplasm, thrombophilia, pregnancy, oral contraceptive use, malignancy.
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- LFTs, INR, FBC, clotting and thrombophilia/myeloproliferative work-up later.
- Doppler ultrasound hepatic veins/IVC.
- CT or MRI venography if ultrasound unclear.
- Diagnostic paracentesis if ascites.
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- Urgent hepatology input.
- Anticoagulation unless contraindicated.
- Treat complications: ascites, varices, liver failure.
- Interventional radiology options: angioplasty/stenting or TIPS.
- Liver transplantation for selected severe/refractory cases.
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| 🧪 Paracetamol Hepatotoxicity |
- May be asymptomatic early.
- Nausea, vomiting, RUQ pain and rising ALT/AST after latent phase.
- Severe cases: metabolic acidosis, hypoglycaemia, INR rise, encephalopathy and renal failure.
- Risk includes staggered overdose, delayed presentation, malnutrition and alcohol dependence.
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- Paracetamol level with timing of ingestion.
- ALT/AST, INR/PT, bilirubin, U&E, creatinine, glucose, VBG/ABG and lactate.
- Repeat bloods to track progression.
- Use TOXBASE/NPIS nomogram/pathway for treatment decisions.
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- Start N-acetylcysteine promptly when indicated.
- If timing unclear, staggered overdose, delayed presentation or abnormal LFT/INR: treat while discussing with TOXBASE/NPIS.
- Monitor glucose, INR, lactate, pH and renal function.
- Discuss severe cases early with liver/transplant centre.
- Psychosocial assessment after overdose.
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