The correct answer is:

acute hepatic failure

Educational Objective:

Recognize the manifestations of acute hepatic failure.

Key Point:

Decompensated cirrhosis and liver failure can imitate DIC. In differentiating DIC  from acute liver decompensation, a history of liver disease/trauma in combination with very abnormal liver lab values is more helpful than D-dimer levels for swaying the diagnosis towards liver failure.

Explanation:

The most likely diagnosis is acute hepatic failure.

Liver failure and decompensated cirrhosis can mimic DIC. Because fibrinogen and other coagulation factors are made in the liver, the fibrinogen level will be low and the PT and PTT will be high in both conditions. Fibrinogen degradation products (D-dimer) may also be elevated in both conditions (in the case of liver failure, this may be due to an inability to clear fibrin degradation products rather than due to exaggerated fibrinolysis as in DIC).

For this reason, an elevated D-dimer level is considered non-contributory for differentiating DIC from liver failure. On the other hand, a low D-dimer level argues against DIC and can therefore be helpful in suggesting liver disease (acute liver decompensation may present with either a high or low D-dimer).

Some clinicians draw a Factor VIII level (the Factor that is low in von Willebrand’s disease) to differentiate liver failure from DIC. Since Factor VIII is NOT synthesized in the liver it tends to be normal in patients with severe liver disease whereas it is low in patients with DIC.

The D-dimer level is not considered to be useful in severe liver disease because it may be either low or high, depending on the type and degree of liver injury. In patients with liver disease and high D-dimer level, it may be due to a lack of clearance of the degradation products rather than exaggerated fibrinolysis.

Unlike DIC, patients with severe liver disease typically present with a known source of liver injury (eg, acute hepatitis, alcoholic cirrhosis) and abnormal liver function tests, although transaminases may appear to normalize if liver synthetic function is severely impaired. Some clinicians consider factor VIII levels to be helpful because factor VIII is not produced by hepatocytes and thus is often low in DIC but high in severe liver disease.

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