Acute liver failure physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Associate Editor(s)-in-Chief: Husnain Shaukat, M.D 
Patients with acute liver failure may appear lethargic, anorexic and fatigue. In the initial stages of acute liver failure, the patient may have mild mental status changes such as altered sleep pattern but may become confused or develop coma in the later stages as the disease progresses. Physical examination of acute liver failure is remarkable for hepatomegaly, right upper quadrant abdominal tenderness, ascites and encephalopathy.
Appearance of the Patient
- Patient with acute liver failure may be appearing ill and lethargic.
- The patients with acute liver failure with mild mental status changes such as altered sleep pattern at initial stages may become confused or develop a comatose condition in the later stage.
- Low-grade fever if the acute liver failure is due to viral infection.
- Hypothermia / hyperthermia may be present.
- Tachycardia may be present in shock liver.
- Low blood pressure may be present in shock liver.
- Vesicular skin lesions can be seen if the acute liver failure is due to herpes simplex infection.
- Signs of easy bruising.
- Icteric sclera
- If the acute liver failure causes cerebral edema, the ophthalmoscopic exam may reveal papilloedema.
- Pupillary changes can also be seen with increased intracranial pressure. In grade I encephalopathy, the pupil may have a normal response. In grade II to III encephalopathy, the pupil can be hyperresponsive. In grade III to IV encephalopathy, the pupil begin to respond slowly.
- Abdominal distention due to ascites
- Diffuse abdominal tenderness.
- Abdominal tenderness in the right upper abdominal quadrant.
The extremities may have signs of easy bleeding due to coagulopathy.
- Hepatic encephalopathy is included in the diagnostic criteria of acute liver failure. The findings in hepatic encephalopathy varies from subtle mental status changes to coma.
- The presence of hepatic encephalopathy is one of the defining characteristics of acute liver failure. Findings in patients with hepatic encephalopathy are variable, ranging from changes in behavior to coma.
Grades of Hepatic Encephalopathy
Based on their clinical manifestation, different grades of hepatic encephalopathy are defined as:
- Grade I
- Grade I encephalopathy manifests with changes in behavior and minimal changes in the level of consciousness.
- Grade II
- Grade II encephalopathy manifests with inappropriate behavior, gross disorientation, drowsiness, and possibly asterixis.
- Grade III
- Grade III encephalopathy manifests with marked confusion, incoherent speech, and mostly sleeping but arousable to vocal stimuli.
- Grade IV
- Grade III encephalopathy manifests with comatose, unresponsive to pain, and decorticate or decerebrate posturing.
- ↑ Mochida S, Nakayama N, Matsui A, Nagoshi S, Fujiwara K (2008). "Re-evaluation of the Guideline published by the Acute Liver Failure Study Group of Japan in 1996 to determine the indications of liver transplantation in patients with fulminant hepatitis". Hepatol Res. 38 (10): 970–9. doi:10.1111/j.1872-034X.2008.00368.x. PMID 18462374.
- ↑ Hoofnagle JH, Nelson KE, Purcell RH (2012). "Hepatitis E." N Engl J Med. 367 (13): 1237–44. doi:10.1056/NEJMra1204512. PMID 23013075.
- ↑ Conn, HO.; Leevy, CM.; Vlahcevic, ZR.; Rodgers, JB.; Maddrey, WC.; Seeff, L.; Levy, LL. (1977). "Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial". Gastroenterology. 72 (4 Pt 1): 573–83. PMID 14049.