Hepatic Disorders and Failure Overview

HEPATIC DISORDERS AND HEPATIC FAILURE

• This chapter reviews epidemiology, pathophysiology, and clinical presentation of acute and chronic liver failure.
• It summarizes laboratory testing, evidence-based emergency diagnosis, and management of hepatic failure complications.
• The complications covered include gastrointestinal hemorrhage, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic encephalopathy.

ACUTE AND CHRONIC LIVER DISEASE

Epidemiology

• Approximately one-third of the US population has acquired immunity to hepatitis A virus (HAV).
• About 125,000-200,000 HAV infections are reported annually, with an estimated 100 deaths.
• Fulminant liver failure is a rare HAV complication.
• Chronic HAV infection does not occur.
• Vaccination against hepatitis B virus (HBV) has significantly reduced fulminant hepatic failure.
• Chronic infection occurs in 6-10% of hepatitis B cases.
• Hepatitis C develops in 85% of those infected, with 70% of those developing chronic liver disease.
• Hepatitis D virus (HDV) is rare and requires concomitant hepatitis B infection to cause infection.
• This type of infection often results in rapid progression & high short-term mortality, especially among intravenous drug users.

Pathophysiology

• Hepatobiliary diseases are categorized by hepatocellular, cholestatic, immunologic, and infiltrative processes.
• Alcoholic liver disease and viral hepatitis are common causes of acute and chronic liver disease.
• Other causes include toxins, drug reactions, autoimmune, and metabolic disorders.
• Cirrhosis develops from fibrous scar tissue mixed with liver cell regeneration, responding to sustained inflammation, toxins, or metabolism insults.
• Scar tissue isolates regenerating liver cells, leading to decreased metabolic function.
• Scarring increases resistance to blood flow within the portal circulation (portal hypertension).
• Reduced blood flow limits metabolic function.
• Portal hypertension causes splenomegaly and gastroesophageal varices.

CLINICAL FEATURES

• Acute liver disease symptoms vary.
• Hepatocellular necrosis (with viral hepatitis): anorexia, nausea, vomiting, low-grade fever.
• Cholestatic disease: jaundice, pruritus, clay-colored stools, dark urine.
• Chronic liver disease presents with various complications:
  • Abdominal pain, ascites, gastrointestinal bleeding, fever, and altered mental status.
  • Progressive generalized fatigue might be the only symptom.
• Other history features to note include sexual behavior, travel, alcohol use, drug use, nutritional supplements intake, blood transfusions, needle exposures, herbal remedies, mushroom consumption, or raw oyster consumption.
• Family history might reveal hereditary conditions causing mild symptoms or laboratory abnormalities (like Gilbert syndrome).
• Severe or premature chronic liver failure is associated with other familial liver disorders (e.g., Wilson disease, hemochromatosis, or α1-antitrypsin deficiency.)