(See also Evaluation of the Patient With a Liver Disorder Evaluation of the Patient With a Liver Disorder History and physical examination often suggest a cause of potential liver disorders and narrow the scope of testing for hepatic and biliary disorders. Various symptoms may develop, but few are... read more and Overview of Acute Viral Hepatitis Overview of Acute Viral Hepatitis Acute viral hepatitis is diffuse liver inflammation caused by specific hepatotropic viruses that have diverse modes of transmission and epidemiologies. A nonspecific viral prodrome is followed... read more .)
Hepatitis B virus is sometimes responsible for fulminant hepatitis, and up to 50% of cases of fulminant hepatitis B involve hepatitis D virus coinfection. Fulminant hepatitis with hepatitis A virus is rare but may be more likely in people with preexisting liver disorders. Occasionally, hepatitis E virus causes fulminant hepatitis. The role of hepatitis C virus remains uncertain.
Alcoholic hepatitis may cause fulminant liver failure, but most patients have a long history of heavy drinking and so probably have underlying chronic liver disease.
Drugs (especially acetaminophen Acute Acetaminophen Poisoning Acetaminophen poisoning can cause gastroenteritis within hours and hepatotoxicity 1 to 3 days after ingestion. Severity of hepatotoxicity after a single acute overdose is predicted by serum... read more ) are the most common cause of fulminant hepatitis in the US.
Symptoms and Signs of Fulminant Hepatitis
Symptoms of fulminant hepatitis develop and become severe very quickly. Patients rapidly deteriorate because portosystemic encephalopathy Portosystemic Encephalopathy Portosystemic encephalopathy is a neuropsychiatric syndrome that can develop in patients with liver disease. It most often results from high gut protein or acute metabolic stress (eg, gastrointestinal... read more develops, progressing to coma and cerebral edema over a period of several days to several weeks. Coagulopathy commonly results from liver failure Acute Liver Failure Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. Treatment is mainly supportive... read more or disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation... read more , and functional renal failure ( hepatorenal syndrome Hepatorenal syndrome Liver disease often causes systemic symptoms and abnormalities. (See also Liver Structure and Function and Evaluation of the Patient With a Liver Disorder.) Hypotension in advanced liver failure... read more ) may develop.
Increasing prothrombin time (PT) or international normalized ratio (INR), portosystemic encephalopathy, and particularly renal failure are ominous.
Diagnosis of Fulminant Hepatitis
Fulminant hepatitis should be suspected if
Patients are acutely ill with new-onset jaundice, rapid changes in mental status, or unexplained bleeding.
Patients with known liver disease rapidly deteriorate.
Laboratory tests to confirm the diagnosis of fulminant hepatitis include liver tests (eg, aminotransferases, alkaline phosphatase) and other tests to evaluate liver function (prothrombin time/international normalized ratio [PT/INR], bilirubin, albumin).
Laboratory tests for acute hepatitis Diagnosis Acute viral hepatitis is diffuse liver inflammation caused by specific hepatotropic viruses that have diverse modes of transmission and epidemiologies. A nonspecific viral prodrome is followed... read more A, B, and C viruses, as well as some other viruses (eg, cytomegalovirus Diagnosis Cytomegalovirus (CMV, human herpesvirus type 5) can cause infections that have a wide range of severity. A syndrome of infectious mononucleosis that lacks severe pharyngitis is common. Severe... read more , Epstein-Barr virus Diagnosis Infectious mononucleosis is caused by Epstein-Barr virus (EBV, human herpesvirus type 4) and is characterized by fatigue, fever, pharyngitis, and lymphadenopathy. Fatigue may persist weeks or... read more , herpes simplex virus Diagnosis Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more ), are done to determine whether a virus is the cause.
The serum acetaminophen level should be measured in all patients if acetaminophen toxicity is suspected.
Treatment of Fulminant Hepatitis
Oral nucleoside or nucleotide analogs
Meticulous medical care, usually in an intensive care unit, and aggressive treatment of complications improve the outcome of patients with fulminant hepatitis.
N-Acetylcysteine is an antidote for acetaminophen poisoning Acetaminophen Poisoning Acetaminophen poisoning can cause gastroenteritis within hours and hepatotoxicity 1 to 3 days after ingestion. Severity of hepatotoxicity after a single acute overdose is predicted by serum... read more . This drug is most effective if given within 8 hours of acetaminophen ingestion but may still have a role in chronic acetaminophen toxicity Chronic Acetaminophen Poisoning Acetaminophen poisoning can cause gastroenteritis within hours and hepatotoxicity 1 to 3 days after ingestion. Severity of hepatotoxicity after a single acute overdose is predicted by serum... read more .
However, emergency liver transplantation Liver Transplantation Liver transplantation is the 2nd most common type of solid organ transplantation. (See also Overview of Transplantation.) Indications for liver transplantation include Cirrhosis (70% of transplantations... read more provides the best hope for survival. Survival in adults is uncommon without transplantation; children tend to do better.
Patients who survive usually recover fully.