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Hepatology Emergencies

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Hepatology Emergency	Clinical Presentation	Diagnostic Tests	Treatment
Acute Liver Failure	Jaundice, coagulopathy (e.g., easy bruising, bleeding), and hepatic encephalopathy (confusion, altered consciousness). May present with nausea, vomiting, right upper quadrant pain, and rapid deterioration in mental status. Common causes include viral hepatitis, drug-induced liver injury (e.g., acetaminophen overdose), and autoimmune hepatitis.	Elevated liver enzymes (AST, ALT), bilirubin, and INR (indicating coagulopathy). Serum ammonia levels elevated, especially with encephalopathy. Viral serologies, toxicology screen, and autoimmune markers to identify the underlying cause.	Immediate transfer to a liver transplant center if eligible for transplantation. Supportive care with IV fluids, glucose, and management of complications (e.g., cerebral edema, coagulopathy). Acetylcysteine for acetaminophen toxicity, even if not presenting in a classic overdose scenario. Consider liver transplantation in cases of fulminant hepatic failure.
Variceal Haemorrhage	Haematemesis (vomiting blood), melena (black, tarry stools), or hematochezia (bright red blood per rectum). Signs of hypovolemic shock, including hypotension, tachycardia, and pallor. History of cirrhosis or chronic liver disease, often with known oesophageal or gastric varices.	Endoscopy to confirm variceal bleeding and to perform therapeutic intervention (e.g., banding, sclerotherapy). CBC showing anaemia and possible thrombocytopenia; coagulation profile may show elevated INR. Blood type and crossmatch for possible transfusion; liver function tests (LFTs) to assess liver status.	Immediate resuscitation with IV fluids and blood transfusions as needed. Vasoactive drugs (e.g., octreotide) to reduce portal pressure and control bleeding. Endoscopic treatment with banding or sclerotherapy; balloon tamponade for uncontrolled bleeding. Antibiotic prophylaxis (e.g., ceftriaxone) to prevent infection and further complications. Consideration of TIPS (transjugular intrahepatic portosystemic shunt) if bleeding is recurrent or refractory to endoscopic treatment.
Spontaneous Bacterial Peritonitis (SBP)	Fever, abdominal pain, and tenderness; worsening ascites. Altered mental status, hypotension, and signs of sepsis in severe cases. History of cirrhosis with ascites.	Diagnostic paracentesis showing ascitic fluid with polymorphonuclear leukocytes (PMNs) ≥250 cells/µL. Ascitic fluid culture typically grows gram-negative bacteria (e.g., E. coli, Klebsiella). Serum and ascitic fluid chemistry tests (e.g., albumin, total protein) to assess severity and guide treatment.	Immediate IV antibiotics (e.g., cefotaxime or another third-generation cephalosporin). IV albumin may be administered to reduce the risk of renal dysfunction. Repeat paracentesis to monitor response to treatment, if clinically indicated. Long-term prophylaxis with antibiotics (e.g., norfloxacin) in patients at high risk for recurrent SBP.
Hepatic Encephalopathy	Altered mental status ranging from confusion to coma; asterixis (flapping tremor) may be present. Jaundice, ascites, and signs of chronic liver disease in known cirrhotic patients. Precipitating factors include infection, GI bleeding, dehydration, electrolyte imbalances, or medications (e.g., sedatives, diuretics).	Serum ammonia levels elevated, though not always correlating with severity. Electrolytes to identify and correct contributing factors (e.g., hypokalemia, hyponatremia). Liver function tests and coagulation profile to assess underlying liver disease severity.	Lactulose to reduce ammonia absorption and promote its excretion; titrate to 2-3 soft stools per day. Rifaximin may be added for patients with recurrent or refractory hepatic encephalopathy. Correction of precipitating factors (e.g., treat infections, discontinue sedatives, correct electrolyte imbalances). Monitoring for progression and supportive care, including airway management in severe cases.
Hepatorenal Syndrome (HRS)	Oliguria, fatigue, and signs of acute kidney injury in a patient with cirrhosis and ascites. Progressive azotemia, hyponatremia, and hypotension. Absence of other causes of renal failure (e.g., shock, nephrotoxic drugs).	Elevated serum creatinine and BUN; low urine sodium (<10 mEq/L). Urinalysis typically bland without significant proteinuria or hematuria. Ultrasound or other imaging to rule out obstruction or parenchymal renal disease.	Volume expansion with IV albumin to improve renal perfusion. Vasoconstrictors (e.g., terlipressin, norepinephrine) to increase systemic vascular resistance. Discontinuation of diuretics and avoidance of nephrotoxic agents. Liver transplantation is the definitive treatment; TIPS may be considered as a bridge to transplantation.
Acute Cholestasis (e.g., Choledocholithiasis)	Right upper quadrant pain, jaundice, and dark urine. Pruritus, pale stools, and signs of systemic infection if cholangitis is present (fever, chills). History of gallstones or biliary surgery.	Elevated liver enzymes with a cholestatic pattern (e.g., elevated ALP, GGT, bilirubin). Ultrasound or MRCP showing dilated bile ducts or stones in the common bile duct. Blood cultures if signs of cholangitis are present.	ERCP for stone removal and biliary drainage; may be combined with sphincterotomy. IV antibiotics if cholangitis is present (e.g., piperacillin-tazobactam, ciprofloxacin plus metronidazole). Surgical consultation for cholecystectomy if gallstones are the underlying cause. Monitoring for complications such as pancreatitis or sepsis.
Alcoholic Hepatitis	Jaundice, anorexia, fever, and right upper quadrant pain. Hepatomegaly, ascites, and encephalopathy in severe cases. History of chronic alcohol abuse.	Elevated liver enzymes (AST > ALT, usually in a ratio >2:1), elevated bilirubin, and INR. Leukocytosis, often with neutrophil predominance. Ultrasound to assess liver size and rule out other causes of liver dysfunction.	Abstinence from alcohol and supportive care, including nutritional support. Corticosteroids (e.g., prednisolone) may be considered in severe cases (Maddrey's discriminant function >32). Pentoxifylline as an alternative if corticosteroids are contraindicated. Monitoring and treatment of complications such as infections, variceal bleeding, or renal failure.
Acute Fatty Liver of Pregnancy	Right upper quadrant pain, nausea, vomiting, and jaundice in the third trimester. Signs of hepatic failure, including encephalopathy and coagulopathy. May be associated with preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets).	Elevated liver enzymes, bilirubin, and INR. Thrombocytopenia, hypoglycemia, and elevated ammonia levels. Ultrasound or MRI may show fatty infiltration of the liver.	Immediate delivery of the fetus, as maternal condition often improves post-delivery. Supportive care with IV fluids, glucose, and management of coagulopathy. Monitoring for complications such as hepatic encephalopathy, renal failure, or sepsis. Postpartum follow-up to assess recovery and liver function.

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