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Late Paracetamol with ALF — RACP Adult Medicine MCQ

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HardGastroenterologyLate Paracetamol with ALFRACP Adult Medicine

A 25-year-old man presents 24 hours after ingesting 30 g of paracetamol. He did not present earlier. He has nausea and RUQ pain. ALT 3500 U/L, AST 4200 U/L, INR 3.8, creatinine 180, bilirubin 65. Paracetamol level is now undetectable. pH is 7.28 (metabolic acidosis). Lactate 6.5. What is the most appropriate management?

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Correct answer: B — Liver transplant referral

Late presentation (>24 hours) with established hepatotoxicity (ALT >3000, coagulopathy, AKI, metabolic acidosis) despite undetectable paracetamol meets King's College Criteria for non-paracetamol ALF (pH <7.3). Start NAC infusion (still beneficial even in established liver failure — improves outcomes), and URGENTLY refer for liver transplant assessment. King's Criteria for paracetamol ALF: pH <7.3 (after resuscitation) OR (INR >6.5 + creatinine >300 + grade III/IV encephalopathy).

Reference: Austin Health Toxicology 2024; King's College Criteria