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Table 77.2

Focused Assessment of the Patient with Possible Acute Liver Failure

  • History
  • Duration and time course of jaundice and other symptoms (e.g. fever, abdominal pain)
  • Known liver or biliary tract disease?
  • Full drug history: including all non-prescription drugs, herbal remedies, dietary supplements, mushroom ingestion or khat, taken over the past year
  • Risk factors for viral hepatitis (foreign travel, IV drug use, men who have sex with men, multiple sexual partners, body piercing and tattoos, blood transfusion and blood products, needle-stick injury in health-care worker)?
  • Pregnancy?
  • Usual and recent alcohol intake?
  • Other medical problems (e.g. cardiovascular disease, transplant recipient, cancer, HIV/AIDS, haematological disease)?
  • Family history of jaundice/liver disease?

Examination

  • Physiological observations and systematic examination
  • Conscious level and mental state; grade of encephalopathy if present:
Asterixis? Ask the patient to hold the arms outstretched with the wrists extended and fingers spread apart, and eyes closed, for 30 seconds or longer. The sign is positive if after a brief latent period, there is a sudden lapse of maintenance of the posture.
Hepatic foetor?
Signs of chronic liver disease?
Right upper quadrant tenderness?
Liver enlargement (seen in early viral hepatitis, alcoholic hepatitis, malignant infiltration, congestive heart failure, acute Budd-Chiari syndrome)?
Splenomegaly?
Ascites (Chapter 24)?
Grading of hepatic encephalopathy
GradeClinical features
Subclinical

Impaired work, personality change, sleep disturbance

Abnormal findings on psychomotor testing

Grade 1

Mild confusion, agitation, apathy, oriented in time and place

Fine tremor, asterixis

Grade 2

Drowsiness, lethargy, disoriented in time

Asterixis, dysarthria

Grade 3

Sleepy but rousable, disoriented in time and place

Hyperreflexia, hyperventilation

Grade 4Responsive only to painful stimuli or unresponsive