What are the next management steps for a patient with viral hepatitis B presenting with worsening jaundice, vomiting, and tremors?

Emergency Management of Hepatitis B with Signs of Hepatic Encephalopathy

The patient should be immediately transferred to the intensive care unit due to signs of hepatic encephalopathy and decompensated liver disease. 1

Clinical Assessment of Current Status

• The patient is showing clear signs of hepatic decompensation with worsening jaundice, acholic stools, dark urine, and tremors of the fingertips, which indicate hepatic encephalopathy - a life-threatening complication 1
• The presence of vomiting (up to 5 times daily), marked weakness, and lack of appetite suggest progressive liver failure 1
• Finger tremors are particularly concerning as they represent asterixis, a cardinal sign of hepatic encephalopathy 1, 2
• The combination of these symptoms on day 10 of hospitalization indicates progression from acute hepatitis B to acute liver failure 1

Immediate Management Steps

• Transfer to ICU for close monitoring of neurological status, hemodynamic parameters, and prevention of further complications 1

• Obtain urgent laboratory tests including:

  • Prothrombin time/INR and factor V (to assess coagulation status) 1
  • Complete blood count and comprehensive metabolic panel 1
  • Arterial blood gases and lactate levels (to assess severity) 1
  • Serum ammonia levels (correlates with encephalopathy) 1
  • Blood, urine, and ascites cultures (if present) to rule out infection 1, 2

• Initiate intravenous fluid therapy with careful attention to electrolyte balance 1

• Maintain serum sodium levels between 140-145 mmol/L to help control cerebral edema 1

• Consider tracheal intubation if encephalopathy progresses (Glasgow Coma Scale <8) 1

Antiviral Therapy

• Start potent nucleos(t)ide analog therapy immediately, regardless of HBV DNA level, as recommended for decompensated disease 1
• Entecavir 1 mg daily (increased dose for decompensated patients) or tenofovir are the preferred treatment options 1
• The goal is to achieve complete viral suppression in the shortest time possible 1
• Early antiviral therapy can improve outcomes and potentially reverse decompensation 1

Supportive Care

• Maintain strict adherence to a high-calorie (30-40 kcal/kg), high-protein (1-1.5 g/kg) diet; consider enteral feeding if unable to eat 1, 3
• Avoid nephrotoxic drugs and use diuretics sparingly to prevent acute kidney injury 1
• Monitor glucose levels at least every 2 hours and correct hypoglycemia promptly 1
• Administer empiric broad-spectrum antibiotics if infection is suspected, as infections often precede multi-organ failure 1, 2

Liver Transplantation Evaluation

• Contact a liver transplant center immediately for evaluation 1
• The patient should be assessed for transplantation eligibility as early as possible 1
• Patients with decompensated HBV cirrhosis should be treated with nucleos(t)ide analogs while awaiting transplantation 1

Monitoring and Further Evaluation

• Perform hepatic Doppler ultrasound to assess portal vein patency and rule out complications 1, 2
• Monitor encephalopathy frequently using standardized scales 1
• Perform echocardiography to assess cardiac function 1
• Monitor for development of other complications including gastrointestinal bleeding, acute kidney injury, and respiratory failure 1

Contraindicated Interventions

• PEG-interferon is absolutely contraindicated in decompensated liver disease 1
• Avoid sedatives such as benzodiazepines which can worsen encephalopathy 1
• Avoid nephrotoxic agents including certain antibiotics and contrast agents 2

This patient requires immediate intensive care management as the clinical picture strongly suggests progression to acute liver failure with hepatic encephalopathy, which carries a high mortality risk without proper intervention.