17. Management of acute liver failure Flashcards
What is acute liver failure?
Acute liver failure (ALF) is the acute deterioration of liver function in a patient without underlying chronic liver disease, characterized by two-to-three times elevation of transaminases
What are liver syndromes?
Liver syndromes are a group of symptoms and signs that indicate liver dysfunction, such as jaundice, coagulopathy, and hepatic encephalopathy.
What is acute-on-chronic liver failure?
Acute deterioration in liver function and extrahepatic organ failures in patients with chronic liver disease with high mortality rate.
What is are symptoms of decompensation of cirrhosis?
- Ascites,
- hepatic encephalopathy,
- renal impairment,
- GI bleeding.
What is the burden of ALF?
There is no clear incidence and prevalence, but it has a very bad prognosis without transplant
What is the classification of ALF based on the time interval between the onset of symptoms (jaundice) and the development of hepatic encephalopathy?
- hyperacute,
- acute,
- subacute,
- chronic liver disease.
What are the characteristics of hyperacute ALF?
- increased transaminase levels,
- severe coagulopathy,
- increase in bilirubin which usually precedes clinical encephalopathy.
What are some causes of hyperacute ALF?
- acetaminophen toxicity
- ischemic hepatopathy.
What are the characteristics of subacute/subfulminant ALF?
- milder increase in serum transaminases,
- deep jaundice,
- mild to moderate coagulopathy,
- splenomegaly,
- ascites,
- shrinking in liver volume
What is Wilson’s disease?
An inherited disease caused by inability to get rid of extra copper, causing copper accumulation in the liver, kidneys…
Other than hepatitis A-E, what viruses can cause hepatitis?
HSV, VZV, EBV, CMV, and adenovirus.
What is AFLP?
Acute fatty liver of pregnancy.
What are the etiological factors of acute liver failure with no pre-existing liver disease?
- autoimmune hepatitis,
- Budd-Chiari syndrome,
- Wilson’s disease,
- hepatitis B infection.
What are danger-associated molecular patterns (DAMPs)?
Molecules released by damaged cells that can trigger an immune response, and leads to organ failure (and death)
What are some complications of acute liver failure?
- CNS disturbances (hepatic encephalopathy, cerebral edema, seizures),
- infections,
- coagulopathy and bleeding,
- renal failure,
- metabolic derangement.
What are the diagnostic methods for acute liver failure?
- History taking,
- clinical signs,
- physical examination of liver and spleen,
- lab results (blood/urine),
- imaging (abdominal US, CT, MRI, Fibroscan/elastography, endoscopy, echocardiography),
- histology (liver biopsy).
What are the symptoms of acute liver failure?
- Jaundice,
- Right upper quadrant pain,
- nausea, vomiting,
- pruritus,
- fatigue, malaise,
- melena/hematemeses.
- mental confusion, difficulty concentrating
What are some physical findings associated with hepatic encephalopathy?
- Icterus (sclera, mucosa, skin),
- neurological signs (flapping tremor, consciousness),
- right upper quadrant tenderness,
- hepatomegaly,
- skin bleedings (petechia, purpura, ecchymosis, suffusion),
- ascites,
- hernias (umbilical, scrotal, inguinal).
What are the laboratory markers used for hepatic encephalopathy?
- AST/GOT,
- ALT/GPT (hepatocellular)
- GGT,
- ALP (alkaline phosphatase)
- total blood count,
- LDH,
- full coagulation screen
- bilirubin, ammonia, albumin, glucose (amylase, lipase)
- arterial blood gas and lactate
- toxicology screen in urine
- paracetamol serum level
- serum pregnancy test
- viral serology, immune markers, Cu markers.
What are the diagnostic criteria for hepatic encephalopathy?
- Prolongation of prothrombin time (INR) ≥ 1.5
- Any degree of hepatic encephalopathy
- No prior evidence of liver diseases
- Disease course of ≤26 weeks.
What is the most common cause of Budd-Chiary syndrome?
Blood clots in the hepatic veins.
What are the indications of liver biopsy?
- To distinguish alf from chronic liver disease
- no exact etiology based on laboratory and imaging tests
What is the course of treatment for acute liver failure?
- Specific treatment is given to treat the underlying cause,
- Supportive care
- Patients must be managed in ICU
What are some characteristics of acute liver failure, such as necrosis and bleeding?
Acute liver failure is characterized by extensive hepatocellular necrosis and sinusoidal bleeding.
