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Acute liver failure in Children : Paediatrics : Summary


Acute liver failure
         Dr Sara Malik

Basic concept: patchy or confluent massive  hepatic necrosis leading to hepatic function deterioration
Definition:
1.biochemical evidence of liver injury  <8 weeks duration
2.no evidence of chronic liver disease
3.PT>15 sec ,INR>1.5  + hepatic encephalopathy
4. PT>20  sec ,INR>2  regardless hepatic encephalopathy
History :
Previously healthy child with progressive jaundice ,fever,anorexia ,vomiting    &
Symptoms of hepatic encephalopathy (Infants -----irritability ,sleep disturbance cycle .
 child ----asterexis)
Examination 
Jaundice
Mucocutaneous bleed
Fluctuation of GCS due to hepatic encephalopathy
Rapid decrease in liver size without clinical improvement (omnious sign)
Signs of respiratory failure in end stage
Laboratory findings:

liver enzyme study
ALT markedly raised
Serum bilirubin increased

Synthetic activity of liver
PT & APTT increased ,not improving after vit k administration
Basal sugar level …low
Serum ammonia normal or increased



Complications of ALF



1.CB(TLC) and complete urine examination  for sepsis
2 .seum electrolytes for dilutional affect on sodium & potassium
3.ABG -----------------metabolic acidosis  & later respiratory alkalosis
4.renal function test for renal dysfunction


                                                 Management
1.prevention of hypoglycaemia
2. correction of coagulopathy…..inj vit k parenterally or later FFP (FFPS may be needed upto 6hrly) (keep NG passed in stomach to watch for hidden GI bleeding)
3.correction of dehydration ..isotonic fluids
4. Clear the gut of free ammonia by giving sodium benzoate 1ml/Kg/ per Ng  8 Hrly
5. clear the gut off ammonia producing bacteria by giving tablet Rifixamine (10 mg per kg)
6. In grade- I encephalopathy , Flumazenil 0.01mg/kg/ O.D has a good role in reversal of encephalopathy.
7. Prevention of constipation by giving syp lactulose per Ng X 8Hrly.
8. If there is acute liver failure of infancy then, antifungal prophylaxis is indicated.
Syp or inj Fluconazole ( load with 12mg per kg , then 6mg/kg O.D after 24 hours of first dose)

Cause management:
N –acetyl cysteine
Acetaminophen poisoning
Acyclovir
Herpes simplex viral infection
Entacavir/ Lamividine
Hep B virus
Prednisolone
Autoimmune hepatitis
pencillamine
Wilson disease

Complications management:
1.Cerebral edema prevention by head up,restrict fluids
Mechanical ventilation & oxygen supplementation may be required
Do not use sedatives
Opiates are better than benzodiazepenes
2. Prevent sepsis by broad spectrum antibiotics as gram positive organisms are most common including Staphylococcus aureus,staphylococcus epidermidis
3.prevent gastrointestinal bleeding by H2 blockers or PPI
Life saving treatment: If advanced liver failure ,liver transplantation required



 One of the first duties of the physician is to educate the masses not to take medicine.

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