Case history
Case history
A 48-year-old woman with a history of migraine headaches presents to the emergency room with altered mental status over the last several hours. She was found by her husband, earlier in the day, to be acutely disoriented and increasingly somnolent. On physical examination, she has scleral icterus, mild right upper quadrant tenderness, and asterixis. Preliminary laboratory studies are notable for a serum alanine aminotransferase of 6498 units/L, total bilirubin of 5.6 mg/dL, and INR of 6.8. Her husband reports that she has consistently been taking pain drugs and started taking additional 500 mg acetaminophen pills several days ago for lower back pain. Further history reveals a drug list with multiple acetaminophen-containing preparations.
Other presentations
The defining features of ALF are jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy.[1][2][3][4][6]
Hepatic encephalopathy is generally preceded by the onset of jaundice. Patients may present with associated nonspecific symptoms such as malaise, nausea, and abdominal pain. Hepatic encephalopathy in the setting of ALF may progress rapidly from mild disorientation and hypersomnolence to coma; a rapid course to advanced encephalopathy is associated with an increased risk of cerebral edema and intracranial hypertension.[4][8] Although clinical jaundice is considered a defining feature of ALF, it may not always be present, particularly in hyperacute presentations.
Complications of ALF, such as infection, renal failure, hypoglycemia, acidosis, and shock, may be present at the time of presentation.
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