Management of Acute Fulminant Hepatitis
Patients with acute fulminant hepatitis require immediate ICU admission, comprehensive diagnostic evaluation, and early contact with a transplant center to reduce mortality and morbidity.
Definition and Diagnosis
- Acute liver failure (ALF) is defined as evidence of coagulation abnormality (INR ≥1.5) and any degree of mental alteration (encephalopathy) in a patient without preexisting cirrhosis with illness duration <26 weeks 1
- Fulminant hepatitis specifically refers to encephalopathy occurring within 15 days of jaundice onset 1
- Immediate measurement of prothrombin time and assessment for mental status changes are essential for diagnosis 1
Initial Management
Immediate Actions
- Transfer to ICU immediately upon diagnosis due to rapid progression potential 1
- Systematic administration of N-acetylcysteine regardless of suspected etiology 1
- Early contact with liver transplant unit for all patients 1, 2
Essential Diagnostic Workup
Comprehensive laboratory evaluation including: 1
- Prothrombin time/INR, factor V
- Complete blood count
- Comprehensive metabolic panel
- Arterial blood gases and lactate level
- Arterial ammonia level
- Acetaminophen level
- Toxicology screen
- Viral hepatitis serologies (IgM HAV, HBsAg, anti-HBc IgM, anti-HEV, anti-HCV)
- Autoimmune markers
- Ceruloplasmin level (for Wilson disease)
- Pregnancy test in females
Imaging and other diagnostics: 1
- Hepatic Doppler ultrasound
- Echocardiography
- Consider transjugular liver biopsy in cases of indeterminate etiology 2
Etiology-Specific Treatment
- Viral hepatitis: Supportive care for hepatitis A and B; no virus-specific treatments have proven effective 2
- Herpes virus hepatitis: Immediate acyclovir treatment and listing for transplantation 2
- Autoimmune hepatitis: Corticosteroids (prednisone 40-60 mg/day) and listing for transplantation 1, 2
- Wilson disease: Consider liver transplantation (uniformly fatal without it); use albumin dialysis, continuous hemofiltration, or plasma exchange to lower serum copper 2
- Drug-induced hepatotoxicity: Discontinue all non-essential medications 2
- Mushroom poisoning: Administer penicillin G and silymarin; list for transplantation 2
Supportive Care Management
Central Nervous System Management
- Monitor encephalopathy frequently 1
- Maintain serum sodium levels between 140-145 mmol/L 1
- Perform tracheal intubation and sedation for progressive hepatic encephalopathy (Glasgow <8) 1
- Avoid sedatives such as benzodiazepines and psychotropic drugs 1
- Avoid treatments like lactulose or rifaximin to lower ammonia levels 1
- Position patient with head elevated at 30 degrees 2
Hemodynamic Support
- Careful fluid resuscitation to maintain adequate intravascular volume 2
- Use crystalloid fluids as first choice for fluid expansion 1
- If fluid replacement fails to maintain mean arterial pressure of 50-60 mmHg, use vasopressors (norepinephrine preferred) 1, 2
- Consider pulmonary artery catheterization in hemodynamically unstable patients 2
Metabolic Management
- Monitor blood glucose at least every 2 hours and manage hypoglycemia with continuous glucose infusions 1, 2
- Monitor and supplement phosphate, magnesium, and potassium levels 2
- Initiate early enteral feeding with moderate protein intake (approximately 60 grams/day) 2
Renal Support
- Avoid nephrotoxic drugs including NSAIDs 1
- Use continuous renal replacement therapy rather than intermittent hemodialysis if dialysis is required 2
Coagulation Management
- Administer vitamin K 2
- Reserve fresh frozen plasma for invasive procedures or active bleeding 2
- Administer platelets for counts <10,000/mm³ or before invasive procedures 2
Infection Prevention
- Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of SIRS 1
- Provide stress ulcer prophylaxis with H2 blockers or proton pump inhibitors 2
Liver Transplantation
- Urgent liver transplantation is indicated when prognostic indicators suggest high likelihood of death 2
- Poor prognostic indicators include: idiosyncratic drug injury, non-hepatitis A viral infections, autoimmune hepatitis, mushroom poisoning, Wilson disease, and indeterminate cause 2
- Post-transplant survival rates for ALF are as high as 80-90% 2
Liver Support Systems
- Various liver support systems have been tested with no definitive evidence of efficacy 2
- Sorbent systems may show transient improvement of hepatic encephalopathy but no improvement in long-term outcomes 2
- Recent studies show improved short-term survival with porcine hepatocyte-based bioartificial liver in some patients 2
Common Pitfalls to Avoid
- Delaying transfer to a transplant center 1, 2
- Failing to identify specific etiologies that might influence treatment 2
- Using benzodiazepines for sedation 1
- Administering nephrotoxic agents 1
- Routine correction of coagulation abnormalities without active bleeding 1
- Delaying corticosteroid treatment in suspected autoimmune hepatitis 1, 2