A 64-year-old man presents to the emergency department following a week of worsening confusion and abdominal pain. He reports a month of worsening fatigue and malaise but has no other symptoms. Past medical history includes hypertension, gout, and frequent presentations to the emergency department with alcohol toxicity, although he denies recreational drug use. His temperature is 37.8°C (100°F), heart rate 104 beats/min, and remaining vital signs are within normal limits. On physical examination, his Glasgow Coma Score (GCS) is 14 (Eyes 4, Voice 4, Motor 6) and he appears extremely jaundiced. Abdominal examination reveals distension with generalized tenderness, evidence of free fluid, and hepatomegaly.
Given the most likely diagnosis, which of the following findings would suggest an impending life-threatening cerebral complication?
E) Irregular breathing
The most likely diagnosis is acute liver failure since the patient has a strong history of alcohol abuse and presents with severe jaundice and confusion. A complication of acute liver failure is cerebral edema, which left untreated may result in raised intracranial pressure and eventually brainstem herniation. Cushing’s triad of hypertension, bradycardia, and irregular breathing is seen with impending brainstem herniation.
Answer choice A: Coarse respiratory crackles, is incorrect. Coarse respiratory crackles may be heard in aspiration pneumonia, but this is more likely treatable by giving antibiotics and airway protection, if required.
Answer choice B: Elevated prothrombin time (PT), is incorrect. Elevated prothrombin time occurs due to impaired synthetic function of the liver. All vitamin K-dependent factors (II, VII, IX, X) will be deficient. However, this typically is not a life-threatening complication unless there is active bleeding.
Answer choice C: Hyperammonemia, is incorrect. Hyperammonemia occurs when the liver cannot convert ammonia into urea for renal excretion. Ammonia readily crosses the blood-brain barrier and increases intravascular oncotic pressure, resulting in cerebral edema and encephalopathy. Hyperammonaemia may result in raised intracranial pressures.
Answer choice D: Hypotension, is incorrect. Hypotension and shock may occur in the context of secondary infection or variceal bleeding and would require immediate treatment, but worsening hypertension would be more suggestive of impending critical complications.
Key Learning Point
Acute liver failure may result in cerebral edema, which causes increased intracranial pressure and may lead to brainstem herniation. Cushing’s triad of hypertension, bradycardia, and irregular breathing is seen with impending brainstem herniation.
