Clinical Scenario:
An 8-year-old previously healthy boy is admitted with a 6-day history of fever, vomiting, and jaundice. He is positive for IgM anti-HAV. On the second hospital day, he becomes increasingly irritable and subsequently develops drowsiness. Examination reveals jaundice, asterixis, and a tender hepatomegaly. Laboratory investigations show:
- Total bilirubin: 12.8 mg/dL
- AST: 2,850 U/L
- ALT: 3,120 U/L
- INR: 3.4
- Serum ammonia: 168 μmol/L
- Blood glucose: 48 mg/dL
He has no previous history of liver disease.
What is the most appropriate next step in management?
A. Start intravenous acyclovir
B. Begin intravenous N-acetylcysteine and urgently refer for liver transplantation assessment
C. Increase intravenous fluids and repeat liver function tests after 24 hours
D. Start oral prednisolone
E. Ursodeoxycholic acid
Correct answer & Explanation:
Correct answer: B. Begin intravenous N-acetylcysteine and urgently refer for liver transplantation assessment
Explanation: Management of Acute Liver Failure
This child has acute liver failure secondary to hepatitis A, evidenced by:
- Hepatic encephalopathy (irritability, drowsiness, asterixis)
- Coagulopathy (INR >1.5)
- Hypoglycaemia
- Hyperammonemia
Acute liver failure is a rare but life-threatening complication of hepatitis A.
Management includes:
- Admission to a pediatric intensive care unit
- Correction of hypoglycaemia and electrolyte abnormalities
- Treatment of cerebral edema if present
- Intravenous N-acetylcysteine, which has been shown to improve transplant-free survival in selected patients with non-acetaminophen acute liver failure, particularly when administered early
- Early referral to a liver transplant center, as deterioration can be rapid
Why the other options are incorrect
A. Intravenous acyclovir
- Used for herpes simplex virus hepatitis, not hepatitis A.
C. Repeat liver function tests after 24 hours
- Delay is inappropriate in a child with acute liver failure and encephalopathy.
D. Oral prednisolone
- Has no role in acute viral hepatitis A.
E. Ursodeoxycholic acid
- May improve cholestatic symptoms but has no role in acute liver failure.
High-yield exam pearl
The degree of transaminase elevation does not predict prognosis in acute viral hepatitis. The development of encephalopathy and prolongation of INR are the most important indicators of acute liver failure and the need for urgent liver transplant assessment.
References
- Squires JE, Alonso EM, Ibrahim SH, et al. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology. 2014;60(1):362-398.
- Lee WM, Hynan LS, Rossaro L, Fontana RJ, Stravitz RT, Larson AM, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137(3):856-864. doi:10.1053/j.gastro.2009.06.006.
You can also practice another MCQ on Hepatitis-B Birth Prophylaxis
