Definition
• Yellowing of the skin as a result of elevated bilirubin (>3 mg/dL)
Approach
• Duration, associated pain, fever, recent travel, h/o liver dz or alcohol abuse
• Labs: CBC, BMP, UA, LFTs, lipase, ±ammonia if MS changes, paracentesis if ascites
Cirrhosis
Definition
• Fibrosis & nodular regeneration resulting from hepatocellular injury
• Etiologies include alcohol, viral hepatitis (esp HCV), autoimmune hepatitis, hemochromatosis, Wilson dz, α1-antitrypsin deficiency, biliary tract dz, vascular dz (Budd–Chiari syndrome, right-sided CHF, constrictive pericarditis), nonalcoholic fatty liver dz, malignancy (usually metastatic)
History
• Abdominal pain, jaundice, pruritus, abdominal distension
Physical Findings
• Liver: Enlarged palpable liver or shrunken nodular
• Signs of liver failure: Jaundice, spider angioma, palmar erythema, gynecomastia, asterixis, encephalopathy
• Signs of portal HTN: Splenomegaly, ascites, caput medusae
Evaluation
• New onset: LFTs, BMP, CBC (for anemia, thrombocytopenia), INR (to evaluate synthetic function), abdominal U/S if pain, tenderness, or fever present to r/o acute biliary dz or if concern for Budd–Chiari, paracentesis if new-onset ascites
• Exacerbation/decompensation of known cirrhosis: Labs to evaluate for electrolyte derangements, new coagulopathy. Paracentesis to r/o SBP if fever, abdominal pain, tenderness, new hepatic encephalopathy, GIB, significant leukocytosis, renal failure.
Treatment
• Directed at treating cx
• Hepatic encephalopathy (failure of liver to detoxify ammonia & other agents): Protein restriction, lactulose (goal 2–4 stools/d)
Disposition
• Admit if decompensated (increasing ascites/edema despite compliance w/ outpt regimen), pulmonary edema, renal failure, hypotensive, encephalopathic, febrile
Pearl
• Cx: Portal HTN (ascites, varices), encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, infections (relative immunosuppression), HCC
Acute Liver Failure
Definition
• Acute hepatic dz often w/ coagulopathy & encephalopathy
• Fulminant liver failure is when encephalopathy occurs <8 wk since onset of 1st sx
• Common etiologies: Viral hepatitis, drugs (40% acetaminophen), toxins (mushrooms), Reye’s syndrome, vascular (Budd–Chiari, CHF), autoimmune hepatitis, idiopathic (20%)
History
• Abdominal pain, jaundice, toxic ingestion, nausea, vomiting, malaise, confusion
Physical Findings
• Jaundice, abdominal tenderness, enlarged liver, encephalopathy, pulmonary edema, GIB (decreased clotting factors, DIC)
Evaluation
• Labs: CBC (anemia, thrombocytopenia), PT/INR, BMP (electrolytes, renal function), acetaminophen level, viral serologies
• Paracentesis if ascites (32% have SBP)
Treatment
• Treat underlying causes (eg, acetaminophen w/ NAC)
• If etiology unclear have low threshold for NAC regardless of acetaminophen level
• Abx: Broad-spectrum (Vancomycin + 3rd-generation cephalosporin)
• Coagulopathy/GIB: Vit K, FFP, platelets, cryoprecipitate if active hemorrhage
• Cerebral edema: Consider ICP monitoring, mannitol, barbiturates
Disposition
Admit medicine. ICU if fulminant, hypotensive, or GIB.
Pearl
Survival 10–50%