GI and General surgery > Liver failure > Flashcards

Liver failure Flashcards

(37 cards)

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1
Q

What is the definition of liver failure?

A

Recognised by the development of coagulopathy (INR > 1.5) and encephalopathy. It can occur suddenly (acute liver failure), or (more often) on a background of cirrhosis (chronic liver failure)

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2
Q

What is Fulminant hepatic failure?

A

Clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function. It develops in under 2 weeks in a patient with a previously normal liver.

Cases which occur more slowly than this are known as subacute subfulminant hepatic failure

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3
Q

What are causes of fulminant hepatic failure?

A
  • Viral Hepatitis - A, B, D, E
  • Drugs - analgesia, MOAI, Halothane, Anti-TB, Antiepileptics
  • Toxins - Carbon tetrachloride, Amantia phalloides mushrooms
  • Wilson’s disease
  • Acute fatty liver of pregnancy
  • Budd Chiari syndrome
  • Autoimmune hepaititis
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4
Q

What are infectious causes of liver failure?

A
  • Viral hepatitis
  • CMV
  • Yellow fever
  • Leptospirosis
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5
Q

What are causes of of acute liver failure?

A
  • Paracetamol (acetaminophen) overdose,
  • Idiosyncratic reaction to medication
  • Excessive alcohol consumption
  • Viral hepatitis (hepatitis A or B)
  • Acute fatty liver of pregnancy
  • Idiopathic (without an obvious cause)
  • Wilsons disease - rare
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6
Q

What are causes of chronic liver failure?

A
  • Alcohol
  • Autoimmune – autoimmmune hepatitis, PBC, PSC
  • Haemochromatosis
  • Chronic Viral hepatitis: B & C
  • Non-alcoholic fatty liver disease (NAFLD)
  • Drugs (MTX, amiodarone)
  • Cystic fibrosis
  • A1-antitryptin deficiency
  • Wilsons disease
  • Vascular problems (Portal hypertension + liver disease)
  • Sarcoidosis
  • Amyloidosis
  • Schistosomiasis
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7
Q

What are symptoms seen in acute liver failure?

A
  • Jaundice
  • Abdominal pain
  • Nausea
  • Vomiting
  • Malaise
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8
Q

What are features of grade 1 hepatic encephalopathy?

A
  • Sleep reversal
  • Altered mood/behaviour
  • Mild lack of awareness/Shortened attention span
  • Impaired computations
  • Dyspraxia - 5 point star
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9
Q

What are features of grade II hepatic encephalopathy?

A
  • Increasing drowsiness/lethargy
  • Confusion
  • Slurred speech
  • May have liver flap
  • Personality change
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10
Q

What are features of grade III hepatic encephalopathy?

A
  • Somnolence/Stuporous
  • Confusion/disorientation/Incoherent
  • Restless
  • Asterixis
  • Hyperreflexia
  • Nystagmus
  • Clonus
  • Rigidity
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11
Q

What are features of grade IV hepatic encephalopathy?

A

Coma

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12
Q

How does hepatic encephalopathy occur?

A

As liver fails, nitrogenous waste builds up in the circulation and passes into the brain, where astrocytes clear it (by processes involving the conversion of glutamate to glutamine).

Excess glutamine causes an osmotic imbalance and a shift of fluid into these cells, leading to cerebral oedema

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13
Q

What signs can be present in compensated chronic liver disease?

A

Indicative of the cause

  • Xanthelasmas
  • Parotid enlargement
  • Spider naevi
  • Hepatomegaly
  • Splenomegaly
  • Palmar erythema
  • Gynaecomastia
  • Clubbing
  • Dupuytren’s contracture
  • Xanthomas
  • Scratch marks
  • Testicular atrophy
  • Purpura
  • Pigmented ulcers
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14
Q

What are signs of decompensated chronic liver disease/acute liver failure?

A
  • Decreased GCS/Altered mental state
  • Asterixis
  • Clonus
  • Nystagmus
  • Hyperreflexia
  • Fetor hepaticus
  • Loss of proximal muscle bulk
  • Ascites
  • Peripheral Oedema
  • JVP elevation
  • Signs of cause - chronic liver disease signs - Caput medusa etc.
  • Jaundice
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15
Q

What investigations would you consider doing in someone with suspected acute liver failure?

A
  • Bloods - FBC, U+E’s, LFT, Clotting, glucose, paracetamol level, hepatitis screen, CMV/EBV serology, ferritin, A1-antitrypsin, caeruloplasmin, autoantibodies, blood/urine cultures, pregnancy test, ABG
  • Ascitic Tap
  • CXR
  • AUS + Doppler flow portal veins
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16
Q

What might you see on LFT in someone with liver failure?

Study These Flashcards
A
  • Hyperbilirubinaemia
  • Elevated LFTs
17
Q

What might you find on FBC in someone with features of liver failure?

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A
  • Anaemia
  • Leukocytosis
  • Thrombocytopenia
18
Q

What might you find on U+E’s in someone with acute liver failure?

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A

Features of renal failure

  • Elevated U+E’s
  • Metabolic derangements
19
Q

What might you see when investigating prothrombin time/INR in someone with liver failure?

20
Q

What are complications of liver failure?

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A
  • Cerebral oedema
  • Ascites
  • Bleeding
  • Infection
  • Hypoglycaemia
  • Encephalopathy
21
Q

Why does ascites occur in decompensated liver failure?

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A
  • Sodium and water retention - peripheral arterial vasodilatation and consequent reduction in the effective blood volume
  • Portal hypertension - local hydrostatic pressure and leads to increased hepatic and splanchnic production of lymph and transudation
  • Low serum albumin - reduction in plasma oncotic pressure.
22
Q

How would you manage someone with acute liver failure/decompensated chronic liver failure?

Study These Flashcards
A

Complex - MOVE TO ITU and beware complications (sepsis, hypoglycaemia, GI/variceal bleeds, encephalopathy)

  • ABCDE
  • Treat cause - e.g. autoimmune hepatitis, wilson’s disease
  • NG tube insertion
  • Observations + Fluid status assessment - urine output and CVC
  • Daily bloods - FBC, U+E’s, LFT, INR
  • Consider dialysis/haemofiltration - if renal failure
  • Nutritional support
23
Q

How would you manage cerebral oedema in soemone with liver failure?

Study These Flashcards
A

ITU

  • IV 20% mannitol
  • Hyperventilate
24
Q

How would you manage ascites in someoen with acute/decompensated liver failure?

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A
  • Restrict fluid
  • Low-salt diet
  • Weigh daily
  • Diuretics
25
Why would you not use gentamicin in someone with acute/decompensated liver failure as blind treatment of infection?
Increases risk of renal failure
26
How would you manage bleeding risk in someone with acute/decompensated liver failure?
* **Vitamin K** * **Platelets, FFP and blood as required** * **Endoscopy** - look for bleeding sites
27
How would you manage hypoglycaemia as a complication of acute/decompensated liver failure?
If \< 2mmol/L or symptomatic * **50 mL of 50% glucose IV, then recheck BG measurements regularly**
28
How would you manage hepatic encephalopathy as a complication of acute/decompensated liver failure?
* **20o head-up tilt in ITU** * **Avoid sedatives** * **Correct electrolytes** * **Lactulose** * **Rifaximin**
29
Why might you use lactulose in someone with hepatic encephalopathy?
It is catabolised by bacterial flora to short chain fatty acids which decrease colonic pH and trap NH3 in the colon as NH4+
30
What is hepatorenal syndrome?
**Cirrhosis + ascites + renal failure** - Abnormal haemodynamics causes splanchnic and systemic vasodilation (due to bacterial translocation, cytokines and mesenteric angiogenesis), but renal vasoconstriction caused by altered renal autoregulation
31
Why might you use Rifaximin in management of hepatic encephalopathy?
Non-absorbable antibiotic that decreases numbers of nitrogen forming bacteria in the gut
32
What are the KCH criteria for paracetamol-induced liver failure?
* **Arterial pH \< 7.3 24 h after ingestion** OR, all of the following * **PT \> 100s** * **Creatinine \> 300 umol/L** * **Grade III/IV encephalopathy**
33
What are the KCH criteria for non-paracetamol liver failure?
* **PT \> 100s** OR 3/5 of the following * **Drug induced liver failure** * **Age \< 10 or \> 40yrs old** * **\>1wk from 1st jaundice to encephalopathy** * **PT \> 50s** * **Bilirubin \>/=300 umol/L**
34
What are the KCH criteria for acute liver failure used for?
Predicting poor outcome in acute liver failure and should prompt transplant consideration
35
What drugs should you avoid in liver failure?
* **Drugs that constipate** * **Oral hypoglycaemics** * **Saline containing IVI's**
36
What are hepatotoxic fdrugs?
* **Paracetamol** * **Methotrexate** * **Isoniazid** * **Azathioprine** * **Phenothiazines** * **Oestrogen** * **Salicylates** * **Tetracyclines** * **Mitomycin**
37
What is the defintion of chronic liver disease?
Liver disease that persists beyond 6 months * **Chronic hepatitis** * **Chronic cholestasis** * **Fibrosis and Cirrhosis** * **Others e.g. steatosis** * **Liver tumours**
GI and General surgery
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