Decompensated liver failure not always just about the liver

Authors: Ruth Watson / Editor: Steve Corry-Bass / Reviewer: Tom White / Codes: ACCS LO 2, EnP3, GC2, GP2, GP3, GP7, IP3, MHC1, SLO1, SLO2 / Published: 30/08/2022

A lady in her 50’s, who is a known alcoholic with cirrhosis, presents with a 3 day history of intermittent confusion, abdominal pain and distension. She was brought by ambulance to Emergency Department (ED), on assessment by the paramedics she was found to have a blood sugar of 0.9 which was treated with IM glucagon and glucogel.

On initial assessment she is jaundiced, alert but confused and agitated. Bilateral breath sounds Sats 94% RR 24. Heart sounds are normal, rate 122 sinus tachycardia on her ECG. Tense abdominal distention, jaundice, bedside USS demonstrated free fluid ++, temperature 35.9.

Bloods:

• WCC 26.7 (4-11) x10⁹/L
• Hb 100 (115-165) g/L
• Neutrophils 23.2 (2-7.5) x10⁹/L
• Platelets 394 (150-450) x10⁹/L
• Na⁺ 126 (136-145) mmol/L
• K⁺ 6.0 (3.5-5) mmol/L
• Cl^– 86 (100-108) mmol/L
• Urea 11.8 (2.5-6.4) mmol/L
• Creatinine 161 (100-120) μmol/L
• eGFR 29
• Bilirubin 51 (3-17) μmol/L
• ALT 67 (12-78) U/L
• ALP 380 (50-136) U/L
• GGT 359 (15-85) U/L
• Albumin 13 (35-50) g/L
• CRP 293 (2) nmol/L
• INR 1.8 (0.9-1.3)
• APTT 1.33 (27-42) s
• Fibrinogen 3.4 (1.9-8) g/L
• Blood sugar 1.2 (4-7.8) mmol/L
• Ammonia 345 (11.2-34.5) μmol/L
• Ethanol [not detected]
• Lactate 1.9 (0.5-2) mmol/L

CT Abdomen – cirrhotic liver, free fluid, ruptured dermoid cyst. Bowel nil pathology.