Acute Hepatic Failure
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define acute hepatic failure (AHF) / fulminant hepatic failure (FHF) in children.
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Identify common causes of paediatric acute hepatic failure.
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Recognize the clinical signs, complications, and laboratory features.
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Outline appropriate investigations to evaluate AHF.
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Implement ABCDE-based stabilization and specific therapeutic interventions.
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Monitor complications and manage metabolic derangements.
Description
Acute hepatic failure is severe impairment of hepatic function in a previously healthy child, often developing within hours to weeks. It may present with protracted vomiting, jaundice, hepatomegaly, coagulopathy, hypoglycaemia, electrolyte disturbances, and encephalopathy.
Common Causes of Paediatric Acute Hepatic Failure
| Category | Examples / Notes |
|---|---|
| Viral / Infective | Hepatitis A, B, C, D, HIV, Parvovirus, Herpesvirus, Enterovirus, Adenovirus, Varicella, Echovirus, CMV |
| Drugs | Paracetamol, antituberculous drugs, carbamazepine, sodium valproate, halothane |
| Toxins | Amanita phalloides (mushroom), herbs, traditional medicines |
| Infiltrative | Leukemias, lymphomas |
| Metabolic / Genetic | Wilson’s disease, galactosemia, tyrosinemia |
Clinical Features
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Protracted vomiting
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Jaundice
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Tender hepatomegaly
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Coagulopathy: bruising, petechiae, bleeding
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Hypoglycaemia
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Electrolyte disturbances
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Encephalopathy: early signs include irritability, confusion, drowsiness; older children may show aggression or unusual behaviour
Investigations
| Category | Tests |
|---|---|
| Liver function | Serum albumin, transaminases (AST/ALT), bilirubin (total & direct), alkaline phosphatase |
| Metabolic | Blood glucose, electrolytes, urea, creatinine |
| Haematology / Coagulation | FBC, PT / INR |
| Inflammatory markers | CRP / ESR |
| Imaging | Ultrasound or CT if indicated |
| Etiologic workup | Viral serology, metabolic screening, drug/toxin history |
Management (ABCDE-based Stabilization)
| Step | Action / Notes |
|---|---|
| A – Airway | Ensure patency; monitor for encephalopathy and risk of aspiration |
| B – Breathing | Oxygen by nasal cannula or face mask as needed |
| C – Circulation | Maintain perfusion; monitor fluid balance closely |
| D – Disability | Assess neurological status; manage hypoglycaemia promptly |
| E – Exposure | Maintain normothermia; avoid paracetamol; monitor for skin/mucosal bleeding |
Specific Therapeutic Measures
| Treatment | Dosage / Notes |
|---|---|
| Vitamin K | Stat dose IV or IM: 300 µg/kg (1 month–12 yrs), 10 mg if >12 yrs |
| Fresh frozen plasma | 10 mL/kg IV for active bleeding (GI or other) |
| Glucose support | Maintain blood glucose 4–9 mmol/L using 2/3 of maintenance fluids with 10% dextrose IV or orally |
| Fluid & urine monitoring | Strict fluid balance; aim urine output ≥0.5 mL/kg/hr |
| Electrolyte correction | Correct hypokalaemia; monitor sodium and other electrolytes |
| Antibiotics | Broad-spectrum (e.g., cephalosporins) for sepsis; antifungals if systemic fungal infection (amphotericin IV or fluconazole PO) |
| Encephalopathy management | Lactulose 5–10 mL 2–3 times/day to produce 2–4 soft stools/day; omit if diarrhoea occurs; Neomycin 20–30 mg/kg/day PO q6h, max 2 g/day |
⚠️ Continuous monitoring is essential. Complications such as hypoglycaemia, electrolyte imbalance, coagulopathy, and infection must be promptly addressed.
Key Summary
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Paediatric acute hepatic failure is a life-threatening emergency.
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Causes include viral infections, drugs, toxins, infiltrative disorders, and metabolic diseases.
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Clinical hallmarks: vomiting, jaundice, hepatomegaly, coagulopathy, hypoglycaemia, encephalopathy.
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Investigations: LFTs, coagulation profile, blood glucose, electrolytes, imaging, and etiologic workup.
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Management is ABCDE-based, with fluid and glucose support, correction of coagulopathy, infection prophylaxis, and monitoring of encephalopathy.
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Lactulose and neomycin may be used to reduce ammonia in hepatic encephalopathy.