GIT Dr.

Shaf3y

G.I.T. 2013 15

Fulminant Hepatic Failure

Liver yellow fever hepatitis paracetamol diseases 8 weeks infection drugs

suicidal

paracetamol poisoning

Halothane general anesthesia halothane fulminant hepatic failure As an allergic manifestations fulminant hepatic failure dose

dose high dose

allergy intoxication

hypersensitivity manifestations dose

dose
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intoxication

GIT Dr. Shaf3y

Hypersensitivity Halothane

T.B.

INH INH

hepatotoxic

T.B. Hypersensitivity

fulminant hepatic failure

drugs toxins Alcohol

ethyl alcohol methanol Methanol ethyl alcohol ethyl alcohol

toxic

Methanol

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GIT Dr. Shaf3y

Anyway

fulminant hepatic failure fulminant hepatic failure toxins

400 300

poisoning fulminant hepatic failure

carbon tetra chloride

Poisoning material poisoning

alcohol

Carbon tetra chloride

fulminant Infection Drugs

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GIT Dr. Shaf3y

Toxins occlusion of 4 hepatic veins Budd Chiari viral infection Reyes syndrome fatty liver of pregnancy fulminant hepatic failure

clinical pictures fulminant hepatic failure hepatic encephalopathy fulminant hepatic failure hepatic encephalopathy encephalopathy mechanism ammonia amino acids

chronic liver cell failure

fulminant hepatic failure brain edema Massive edema

fulminant hepatic failure Hepatic encephalopathy ammonia mechanism

cerebral edema chronic liver cell failure cerebral edema

jaundice Jaundice
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so massive cerebral edema brain herniation brain herniation

Hepatic encephalopathy

GIT Dr. Shaf3y

fulminant hepatic failure hepatic encephalopathy Jaundice Liver liver investigations fulminant hepatic failure Missed diagnosis neurological problem Miss diagnosis neurological problem jaundice treatment investigation

Liver function

Hepatic encephalopathy foetor hepaticus jaundice ascites Plamer erythema spider navei

cause of death Hypoglycemia D.I.C. ARDS Hepato renal syndrome

fulminant hepatic failure

Investigations investigations Liver function test Liver function test Enzymes enzymes

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GIT Dr. Shaf3y

normally << SGOT 40 4,000 7,000 Liver enzymes fulminant follow up enzymes Liver has been exhausted exhausted liver enzymes liver enzymes

Liver enzymes Prognosis

Investigations

Liver enzymes Albumin Normal acute liver diseases Normal albumin

Prolonged

Prothrombin time Prognosis prothrombin time

prothrombin time

bilirubin
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GIT Dr. Shaf3y

bilirubin biphasic Prognosis bilirubin

Prognosis bilirubin prothrombin time

bilirubin

diagnosis << enzymes prothrombin time << Prognosis

affected organs

blood glucose arterial blood gases X ray edema brain CT detect coagulation profile investigations for the cause Hepatitis markers

treatment ICU N acetyl cystiene cause paracetamol poisoning

Hepatitis ICU care of comatosed ICU care of comatosed care of bowel care of respiration care of skin

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GIT Dr. Shaf3y

hypoglycemic hepato renal syndrome ventilator << ARDS platelets plasma << D.I.C. symptomatic Just 95 % survival 5 % 5% proliferation Liver replacement

dialysis

Liver has been damaged

Liver transplantation liver transplantation

95 % ICU fulminant equipment available ICU

transplantation transplant list Patient

fulminant ICU transplantation transplant list ICU

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GIT Dr. Shaf3y

maximum immune suppression complications Normal

95 % criteria 95 % recovery

fulminant Prothrombin time 100 Prognostic marker

fulminant hepatic failure Prothrombin time 100

Not improving

Prothrombin time 4 3 50 Prothrombin time 40 Age hepatic encephalopathy 300 bilirubin

100

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GIT Dr. Shaf3y

criteria

fulminant hepatitis

Hepatitis
acute hepatitis hepatitis Inflammation of the liver acute

Acute hepatitis Is inflammation of the liver less than 6 months

Liver

acute hepatitis inflammation

acute hepatitis hepatitis A, B, C, D, E, G viruses

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GIT Dr. Shaf3y

acute yellow fever virus Epstein-Barr virus cytomegalo virus acute hepatitis

acute hepatitis hepatitis viruses A, B, C, D, E

Hepatitis A virus RNA DNA B virus RNA hepatitis A virus RNA Mode of transmission Feco-oral blood infection blood viremia Infection virus Infection

hepatitis A

incubation period Manifestations screening blood bank

hepatitis A
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GIT Dr. Shaf3y

viremia feco oral feco oral young adults children

epidemic

sporadic

hepatitis A 500

Hepatitis salmonella

epidemic

sporadic

Anyway Hepatitis A acute attack mild

acute attack without jaundice acute hepatitis A diarrhea Just abdominal pain jaundice diarrhea abdominal pain Hepatitis gastroenteritis hepatitis A gastroenteritis

Mild

Hepatitis A
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GIT Dr. Shaf3y

hepatitis A Immune

complications acute complications fulminant hepatic failure chronic complications chronic complications Incubation period 6 Hepatitis E typical A A E

typical << 27 27

A E fulminant hepatic failure

20 % E fulminant hepatic failure 20 %

fulminant Fulminant hepatic failure

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GIT Dr. Shaf3y

3

playstation

playstation

Hepatitis A fulminant

hepatitis E

Hepatitis B DNA virus mode of transmission blood transfusion Vertical transmission from the mother to the baby Sexual transmission Needles Dialysis machines Mode of transmission

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GIT Dr. Shaf3y

High risk group Doctors and nursing Homosexual Prostitutes Drug addicts

doctors and nurses Homosexual Prostitutes Drug addicts

Hemolytic anemia dialysis

High risk group

70

60

sporadic epidemic epidemic in certain population dialysis epidemic hepatitis B dialysis

epidemic

epidemic Dialysis population Incubation period

acute attack always severe jaundice

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GIT Dr. Shaf3y

jaundice jaundice A

Hepatitis B severe acute attack jaundice complications chronic acute fulminant

cirrhosis

chronic complications acute Hepatitis B Hepatitis D typical B D B D is incomplete virus << D infection as incomplete virus << D infection capsule B capsule B infection B super infection co-infection on-top D B

Hepatitis C RNA C virus

Typical B C

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GIT Dr. Shaf3y

RNA virus C DNA D

mild

acute C jaundice hepatitis C Jaundice

acute C

cirrhosis hepatitis marker C

jaundice anicteric anicteric

Hepatitis C attack

Hepatitis C complications Acute and chronic

doubt

Hepatitis C sexual transmission hepatitis B sexual transmission doubt Hepatitis C

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GIT Dr. Shaf3y

Hepatitis C hepatitis C 30 %

tartar emetic

hepatitis C

theory

hepatitis C

hepatitis markers hepatitis C

Whatever

study

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GIT Dr. Shaf3y

infection infection

fresh infection

dentist

fungus

dentist dentist

fungus

regularly << dentist

dentist dentist insurance dentist it covers the dentist My job covers the dentist

infection

dentist

pain
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GIT Dr. Shaf3y

dentist 30 % hepatitis C

hepatitis G virus G G

hepatitis G virus B C D G

damage C liver damage

C virus G Liver damage G We cannot tell C G

hepatitis G virus A, B, C, D, E, F G F F G

fulminant hepatic failure F hepatitis A virus F fulminant complicated

already fulminant viruses

G etiology

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GIT Dr. Shaf3y

pathology Liver virus virus proliferation virus proliferate hepatocyte proliferate virus virus virus proteins virus proteins

proliferation

non proliferating

dormant

cells surface hepatocytes

proteins immune system

not proliferating surface antigens

virus

hepatocytes immune system

viral infection Lymphocytic infiltration Organ virus surface Lymphocyte is infiltrating virus proteins

Proliferating

virus Hepatocyte

bile duct
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Portal vein

Hepatic lobule Portal area hepatic artery Portal area

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GIT Dr. Shaf3y

Hepatocyte central vein viral infection damage center central zone

viral infection Lymphocytes infiltrated Portal area

viral hepatitis kidney

Pathology liver bone marrow pleura

liver

hepatitis viruses Which is not true Kidney bone marrow

pleura

Clinical pictures clinical pictures Hepatitis icteric type anicteric type complications clinical pictures icteric anicteric jaundice jaundice anicteric Hepatitis A, E, C
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anicteric

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GIT Dr. Shaf3y

E A C anicteric A A

jaundice jaundice

abdominal colics

diarrhea typhoid hepatitis

anicteric fever

undiagnosed

cirrhosis anicteric cirrhosis

hepatitis C C

3 icteric type Pre icteric phase Icteric Post icteric Post icteric icteric Pre icteric Pre icteric jaundice jaundice Fever specially << abdominal pain right hypochondrium vomiting nausea anorexia Especially toward cigarettes

We have no idea

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GIT Dr. Shaf3y

3 icteric Pre icteric Icteric Post icteric

recovery

convalescence

vomiting

nausea

anorexia

pre icteric abdominal pain fever Especially towards cigarettes fever

15

Relative bradycardia relative bradycardia 80 heart rate 40 39 120 110 heart rate heart rate 3 40

45 120 - 115 << heart rate 80 Heart rate relative bradycardia relative bradycardia expected for fever heart rate relative bradycardia abdominal rash spleen enlarged tender liver jaundice manifestations jaundice manifestations fever anorexia

nausea
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GIT Dr. Shaf3y

dark urine clay colored stool jaundice hepatocellular stercobilinogen clay colored stool urine direct bilirubin dark << urine

splenomegaly just in 20 % of patient spleen splenomegaly just palpable spleen spleen 20 convalescence

presentation complications hepatitis complications Hepatic Extra hepatic Hepatic complications complications

complications extra hepatic

hepatic complications Acute chronic chronic acute

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GIT Dr. Shaf3y

acute complications fulminant hepatic failure fulminant fulminant

viruses

post hepatitis cholestasis Post hepatitis cholestasis viral infection Liver edema bile ductules compression hepatocyte Columns bile ductules

viral infection swelling hepatocytes bile ductules compression obstructive jaundice edema jaundice post hepatitis cholestasis

corticosteroids edema edema corticosteroids virus 28 8 edema jaundice 28 8

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flaring

jaundice

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GIT Dr. Shaf3y

post hepatitis cholestasis

Post hepatitis syndrome

Post hepatitis syndrome hepatitis sputum chest infection infection unresolved pneumonia bronchogenic carcinoma

Pleurisy myocardial infarction

chest pain Pain

deny myocardial infarction

Myocardial infarction

Infarction Heart burn esophageal spasm

cardiologist

Anyway hepatitis He covered virus complications

virus

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GIT Dr. Shaf3y

enzymes enzymes enzymes enzymes

science

father of hepatology hepatology female

copula of the diaphragm hepatitis copula of the diaphragm

spasm

spasm

Liver

dome

pain spasm compression Liver copula damage enzymes

relapse Relapse D on top B hepatitis super infection

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GIT Dr. Shaf3y

activation dormant virus relapse Chemical Liver enzymes Clinical jaundice

chemical clinical

Cs

chronic complications chronic complications Cirrhosis Carcinoma Carrier Chronic hepatitis

Extra hepatic complications A, P, C, G arthritis aplastic anemia << A Poly arteritis nodosa << P cryoglobinemia << C glomerulonephritis << G

G.I.T. 2013 16 15

www.facebook.com/dr.tafreegh
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GIT Dr. Shaf3y

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