PE23.14 | Fulminant Hepatic Failure — Summary & Reflection

KEY TAKEAWAYS

Fulminant hepatic failure in children is defined by hepatic encephalopathy + INR >1.5 within 8 weeks, without pre-existing liver disease. In India, hepatitis A and E are the dominant viral causes; Wilson disease must always be considered in older children (low ALP + Coombs-negative haemolysis + low ceruloplasmin are diagnostic clues). Hepatic encephalopathy is graded I–IV (I = mild confusion → IV = unresponsive coma); Grade III–IV warrants ICU care and urgent transplant evaluation. The pathophysiological cascade centres on ammonia accumulation causing cerebral oedema, coagulopathy from failed clotting-factor synthesis, and hypoglycaemia from failed gluconeogenesis. Management priorities: lactulose + avoid sedatives (HE), glucose correction (hypoglycaemia), IV NAC (paracetamol and non-paracetamol FHF), treat active bleeding with FFP/Vitamin K (not prophylactically), broad-spectrum antibiotics for suspected infection, and early liver transplant referral for INR >4 or Grade III–IV HE. Early recognition and timely referral are the two modifiable factors most likely to save the child's life.

REFLECT

Think about a child you might see in a district emergency setting with rapidly worsening jaundice and a drowsy, confused affect. What features would prompt you to say 'this is FHF, not just hepatitis' — and what would you do in the first 30 minutes if you were the doctor in charge? Consider: How would you grade the HE? How would you correct hypoglycaemia if there is no ICU and your resources are limited? At what point would you initiate the phone call to a tertiary centre? Kolb's reflective cycle: describe your reasoning, analyse what you would do, conclude by identifying what you still need to learn, and plan how you will practise recognising HE grading on your next clinical posting.