diuretic (e.g., spironolactone) to achieve a slow, gradual change in ascites is all that is initially required Aggressive diuresis may precipitate or worsen hepatorenal syndrome Patients with encephalopathy should be frequently monitored for changes in neurologic function Bowel therapy with lactulose is a common therapy directed at hyperammonemia Patients with HE should also have medications reviewed for any medication that may worsen their mental status Blood within the GI tract, if present, provides a high protein load and may also worsen HE Patients should also be monitored for signs of elevated ICP Cerebral edema is a major cause of mortality Invasive monitoring, however, has not been shown to improve outcome and can be difficult in the setting of intractable coagulopathies Patients should be monitored in an intensive care setting and neurosurgical consultation is necessary Additional medical treatments include steroids, N-acetylcysteine, and plasmapheresis Steroids have been shown to be beneficial in the setting of adrenal insufficiency, autoimmune hepatitis, or with medication reactions Steroids should not be used nonspecifically with other general causes of ALF Acetaminophen toxicity should be treated aggressively with N-acetylcysteine (see Chapter 102 Toxicologic Emergencies ) N-acetylcysteine may have some benefit in certain groups of patients with non–acetaminophen-induced liver failure, however evidence is lacking for its broad use in all cases of ALF Plasmapheresis has been used to perform the detoxification functions of the liver, however evidence of its benefit on patient outcome is lacking Finally, if medical management has failed, patients may require liver transplant Ten percent to 15% of pediatric liver transplants in the United States are secondary to ALF (see Chapter 125 Transplantation Emergencies ) PORTAL HYPERTENSION Portal hypertension is a clinical syndrome caused by either increased or restricted blood flow within the portal vasculature leading to a splenomegaly and the development of portosystemic blood vessel collaterals as blood is shunted to the systemic vasculature The disease becomes clinically significant when effects of this elevation in pressure or collateral vessels become evident Most patients present with splenomegaly, however some will also present with GI bleeding or ascites The management of these complications is important for the ED provider as they may be life threatening