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Hepatic Failure: An Evidence- Based Approach In The Emergency Department

April 2010


Hepatic failure presents with a variety of acute manifestations, most of which will be seen at some point during the ED clinician’s career. At the most critical end of the spectrum is the syndrome of acute liver failure (ALF), in which hepatic function is suddenly lost in a person with no previous liver dysfunction. Currently, the most widely accepted definition of ALF is the presence of both coagulopathy (international normalized ratio [INR] > 1.5) and altered mental status consistent with hepatic encephalopathy of less than 26 weeks’ duration (a change from the previously defined timeline of 8 weeks).1,2 This disorder is rare, with an annual incidence in the US of 2300 to 2800 cases, and results in 0.1% of all deaths and 6% of all liver-related deaths in the US.3,4 However, this condition can deteriorate rapidly and is associated with high morbidity and mortality. Precipitating etiologies must be quickly identified and disease-specific interventions implemented in order to prevent further decompensation or death. Early transfer to a tertiary care facility with transplant capability may also be necessary.

More common than ALF is chronic liver failure (CLF) with cirrhosis, the 12th leading cause of death in the US.5 While primarily a disorder of long-term outpatient management, acute decompensation of CLF may bring the patient to the ED because of variceal hemorrhage, symptomatic ascites, spontaneous bacterial peritonitis, hepatorenal or hepatopulmonary syndrome, and hepatic encephalopathy. The ED clinician must confront these manifestations and guide management within the broader context of the patient’s chronic care.

This issue of Emergency Medicine Practice focuses on the management of ALF and the acutely symptomatic cirrhotic patient.
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