Acute liver failure

Question 1

Define hyperacute, acute and subacute liver failure

Answer 1

1. Hyperacute: encephalopathy develops within 7d onset of jaundice
2. Acute is within 8-28 days
3. Subacute is when develops 5-26 weeks

Onset of jaundice, coagulopathy INR >1.5 and hepatic encephalopathy in patients with no prior history of liver disease

Question 2

Causes of acute liver failure

Answer 2

1. Infections
Viral hepatitis
Yellow fever
Leptospirosis
2. Drugs
Paracetamol
Halothane
3. Toxins
Poison mushroom
4. Vascular
Budd chiari
Veno-occlusive
5. Other
Alcohol
PBC
Haemachromatosis
AI hepatitis
a1 antitrypsin
Wilson's
Fatty liver of pregnancy
Malignancy
HELLP

Question 3

Risk factors

Answer 3

1. Alcohol
2. Poor nutrition
3. Female
4. > 40 yo
5. Pregnancy
6. Chronic hepatitis B
7. Chronic pain and narcotic use
8. Hepatitis C
9. Paracetamol use

Question 4

History and examination

Answer 4

1. Assess exposures: alcohol, drugs, substance, mushrooms
2. Time course from jaundice to encephalopathy
3. Consider acut on chronic
4. Abdominal pain, nausea, vomiting, hepatomegaly
5. Look for evidence of chronic liver disease, encephalopathy (neurological examination)

Question 5

Grades of hepatic encephalopathy

Answer 5

1. Altered mood/behaviour, sleep disturbance
2. Increased drowsiness, confusion, slurred speech
3. Stupor, incoherence, restlessness, confusion
4. Coma

Question 6

Investigations and interpretation

Answer 6

1. LFTs->+bilirubin, +AST/ALT/GGT
2. Prothrombin time/INR->elevated >1.5
3. UEC, glucose->+urea and creatinine, metabolic derangements
4. FBC->leukocytosis, anemia, thrombocytopenia
5. Blood type and screen
6. ABG->metabolic acidosis
7. Lactate->elevated
8. Paracetamol level
9. Urine toxicology screen
10. Factor V leiden-> low
11. Viral hepatitis serologies, EBV, CMV
12. AI hepatitis markers
    13/ Serum ceruloplasmin, iron studies
13. Pregnancy test
14. CXR-> ?aspiration pneumonia
15. Abdominal USS->look for hepatic vessel thrombosis, hepatomegaly, splenomegaly, hepatic surface nodularity
16. Urine MCS, blood, ascitic tap

Question 7

Six things to look for on USS

Answer 7

1. Bile duct obstruction
2. Stones
3. Metastasis
4. Echogenecity
5. Focal liver lesion
6. Splenomegaly

Question 8

Most important things to be aware of in acute liver failure

Answer 8

1. Hypoglycemia
2. GI bleeds
3. Encephalopathy

Question 9

Management

Answer 9

1. ABC, elevate head of bed, intubation
2. NGT, NBM
3. Urinary catheter
4. IV access
5. Monitor
   Temp, RR, Pulse, BP, urine output, weight daily
   Neurology, ICP
   Cardiorespiratory
   Fluid balance- UEC, ABG
   Coagulation
6. Thiamine, folate
7. 10% IV dextrose. Check BG every 4 hours
8. Treat the cause and complications
   Bleeding->vit K, PLTs, FFP, pRBCs
   Infection->ceftriaxone
   Ascites->fluid restriction, low salt, daily weights
   Hypoglycemia
   Encephalopathy-> avoid sedatives, head tilt, lactulose +/= enemas
   Cerebral edema->Hyperventilate, mannitol
9. Nutrition
10. Consider dialysis if renal failure
11. PPI prophylaxis
12. Avoid sedatives, may use lorazepam
13. Infection control
    Blood culture
    Urine culture
    Throat
    Sputum
    CXR
    Cannula and catheter
14. Lisase with transplant team, seniors
15. Admit to ICU

Question 10

Complications of acute liver failure

Answer 10

1. Bleeding
2. Infection
3. Hypoglycemia
4. Encephalopathy
5. Cerebral edema
6. Renal failure
7. Multi-organ failure

Question 11

Poor prognostic factors

Answer 11

1. Grade 3 or 4 encephalopathy
2. Age >40 years
3. Low albumin
4. +INR
5. Drug induced
6. Late onset