Liver Failure

Question 1

What is liver failure?

Answer 1

Development of coagulopathy and encephalopathy

Question 2

How many days does each of them last?

• hyperacute LF
• acute LF
• subacute LF

Answer 2

• 7 days or less
• 8-21 days
• 4-26 weeks

Question 3

What is liver cirrhosis?

Answer 3

Chronic LF

Question 4

What is fulminant hepatic failure?

Answer 4

Clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function

Question 5

What are the causes of LF?

Answer 5

• Infection
  
  • Hep B, Hep C, CMV
  • yellow fever
  • leptospirosis
• Drugs
  
  • Paracetamol overdose
  • Halothane
  • Isoniazid
• Vascular
  
  • Budd-Chiari syndrome
• Other
  
  • Alcohol
  • Fatty liver disease
  • 1 biliary/sclerosing cholangitis
  • Haemochromatosis
  • Wilson’s disease
  • a1antitrypsin deficiency

Question 6

What are the Sx of LF?

Answer 6

• Jaundice
• Hepatic encephalopathy
• Fetor hepaticus
• Asterixis
• Constructional aprexia

Question 7

What is Budd Chiari Syndrome?

Answer 7

• occlusion of hepatic veins that drain the liver
• Triad
  
  • abdominal pain
  • ascites
  • liver enlargement

Question 8

What is the Px of hepatic encephalopathy?

Answer 8

1. Liver failure > ammonia builds up in circulation > passes to the brain
2. Astorcyte clear it by processess involving conversion of glutamate to glutamine
3. Excess glutamine causes osmotic imbalance
4. Shift of fluids into cells
5. Cerebral oedema

Question 9

What Ix would you order for LF?

Answer 9

• Blood
  
  • FBC, U&E, LFT, Clotting
  • Glucose, paracetamol, hepatitis
  • Ferritin, a1antitrypsin, caeruloplasmin
  • autoantibodies
• Microbiology
  
  • blood culture
  • urine culture
  • ascitic tap
• Radiology
  
  • CXR
  • AUS
  • Doppler flow

Question 10

What criteria is used for acute LF?

Answer 10

King’s College Hospital Criteria

Question 11

What is the King’s College Hospital criteria for paracetamol induced liver failure?

Answer 11

• Arterial pH <7.3 24h after ingestion

Or all of the following:
• Prothrombin time (PT) >100s
• Creatinine >300μmol/L

• Grade III or IV encephalopathy.

Question 12

What is the King’s College Hospital criteria for non paracetamol induced liver failure?

Answer 12

• PT >100s.

Or 3 out of 5 of the following:

• Drug-induced liver failure
• Age <10 or >40yrs old
• >1wk from 1st jaundice to encephalopathy
• PT >50s
• Bilirubin ≥300μmol/L.

Question 13

What are the four grades of hepatic encephalopathy?

Answer 13

1: Altered mood, sleep disturbance, dyspraxia poor arithmetic. No liver flap.
2: Increasing drowsiness, confusion, slurred speech ± liver flap, inappropriate behaviour/personality change
3: Incoherent; restless; liver flap; stupor
4: Coma

Question 14

How would you Mx LF?

Answer 14

• Intubate and NG tube
• urinary and central venous catheter
• 10% glucose IV, 1L/12hr
• Tx underlying cause
• Thiamine and folate supplements
• Phenytoin if seizures
• Haemodialysis if RF
• Avoid drugs c hepatic metabolism
• Consider PPI

Question 15

What are the things to monitor in LF?

Answer 15

• Hourly
  
  • Temperature
  • respirations
  • pulse
  • BP
  • UO
  • pupils
• Daily
  
  • FBC
  • U&E
  • LFT
  • INR

Question 16

What are the Cx of LF?

Answer 16

• CO
• Ascites
• Bleeding
• Encephalopathy
• Low blood glucose