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1. Internal Medicine I > 17. Management of acute liver failure > Flashcards

17. Management of acute liver failure Flashcards

1
Q

What is acute liver failure?

A

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

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2
Q

What are liver syndromes?

A

Liver syndromes are a group of symptoms and signs that indicate liver dysfunction, such as jaundice, coagulopathy, and hepatic encephalopathy.

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3
Q

What is acute-on-chronic liver failure?

A

Acute deterioration in liver function and extrahepatic organ failures in patients with chronic liver disease with high mortality rate.

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4
Q

What is are symptoms of decompensation of cirrhosis?

A
  • Ascites,
  • hepatic encephalopathy,
  • renal impairment,
  • GI bleeding.
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5
Q

What is the burden of ALF?

A

There is no clear incidence and prevalence, but it has a very bad prognosis without transplant

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6
Q

What is the classification of ALF based on the time interval between the onset of symptoms (jaundice) and the development of hepatic encephalopathy?

A
  • hyperacute,
  • acute,
  • subacute,
  • chronic liver disease.
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7
Q

What are the characteristics of hyperacute ALF?

A
  • increased transaminase levels,
  • severe coagulopathy,
  • increase in bilirubin which usually precedes clinical encephalopathy.
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8
Q

What are some causes of hyperacute ALF?

A
  • acetaminophen toxicity
  • ischemic hepatopathy.
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9
Q

What are the characteristics of subacute/subfulminant ALF?

A
  • milder increase in serum transaminases,
  • deep jaundice,
  • mild to moderate coagulopathy,
  • splenomegaly,
  • ascites,
  • shrinking in liver volume
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10
Q

What is Wilson’s disease?

A

An inherited disease caused by inability to get rid of extra copper, causing copper accumulation in the liver, kidneys…

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11
Q

Other than hepatitis A-E, what viruses can cause hepatitis?

A

HSV, VZV, EBV, CMV, and adenovirus.

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12
Q

What is AFLP?

A

Acute fatty liver of pregnancy.

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13
Q

What are the etiological factors of acute liver failure with no pre-existing liver disease?

A
  • autoimmune hepatitis,
  • Budd-Chiari syndrome,
  • Wilson’s disease,
  • hepatitis B infection.
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14
Q

What are danger-associated molecular patterns (DAMPs)?

A

Molecules released by damaged cells that can trigger an immune response, and leads to organ failure (and death)

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15
Q

What are some complications of acute liver failure?

A
  • CNS disturbances (hepatic encephalopathy, cerebral edema, seizures),
  • infections,
  • coagulopathy and bleeding,
  • renal failure,
  • metabolic derangement.
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16
Q

What are the diagnostic methods for acute liver failure?

A
  • 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).
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17
Q

What are the symptoms of acute liver failure?

A
  • Jaundice,
  • Right upper quadrant pain,
  • nausea, vomiting,
  • pruritus,
  • fatigue, malaise,
  • melena/hematemeses.
  • mental confusion, difficulty concentrating
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18
Q

What are some physical findings associated with hepatic encephalopathy?

A
  • 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).
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19
Q

What are the laboratory markers used for hepatic encephalopathy?

A
  • 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.
20
Q

What are the diagnostic criteria for hepatic encephalopathy?

A
  1. Prolongation of prothrombin time (INR) ≥ 1.5
  2. Any degree of hepatic encephalopathy
  3. No prior evidence of liver diseases
  4. Disease course of ≤26 weeks.
21
Q

What is the most common cause of Budd-Chiary syndrome?

A

Blood clots in the hepatic veins.

22
Q

What are the indications of liver biopsy?

A
  • To distinguish alf from chronic liver disease
  • no exact etiology based on laboratory and imaging tests
23
Q

What is the course of treatment for acute liver failure?

A
  • Specific treatment is given to treat the underlying cause,
  • Supportive care
  • Patients must be managed in ICU
24
Q

What are some characteristics of acute liver failure, such as necrosis and bleeding?

A

Acute liver failure is characterized by extensive hepatocellular necrosis and sinusoidal bleeding.

25
Q

What is the specific therapy for autoimmune hepatitis?

A

Glucocorticoids with careful consideration of infection risk.

26
Q

What is the management for Amanita phalloides poisoning?

A
  • Gastric aspiration, lavage
  • activated charcoal,
  • silibinin,
  • penicillin G,
  • N-acetylcysteine.
27
Q

What are the treatment options for Budd-Chiari syndrome?

A

Transjugular intrahepatic shunt placement, surgical decompression, thrombolysis.

28
Q

What is the recommended treatment for acetaminophen intoxication?

A

N-acetylcysteine.

29
Q

What kind of supportive therapy is given for ALF?

A
  • Haemodynamic stabilisation (fluids, vasopressorsà
  • Ventilatory support
  • Renal replacement therapy
  • Broad spectrum antibiotics for infections
30
Q

What is the recommended treatment for hepatic encephalopathy in patients with liver cirrhosis?

A

Lactulose and rifaximin, although rifaximin is controversial.

31
Q

What are some metabolic abnormalities that can occur in patients with liver cirrhosis?

A
  • Acidosis,
  • hypokalaemia,
  • hyponatraemia,
  • hypophosphataemia,
  • hypoglycaemia.
32
Q

What are some coagulation abnormalities that can occur in patients with liver cirrhosis?

A
  • Diminished synthesis of coagulation factors,
  • reduction of platelet count and abnormal platelet function,
  • increased risk of hypercoagulability.
33
Q

What are some examples of haemoderivates that can be administered before invasive procedures in patients with liver cirrhosis?

A

Fresh frozen plasma, protrombin complex, cryoprecipitate, and thrombocyte replacement.

34
Q

What percentage of ALF patients suffer from intracranial hypertension?

A

50%.

35
Q

What are the supportive management techniques for intracranial hypertension?

A
  • Elevation of patient’s head at 30 degrees,
  • Valsalva manoeuvres,
  • proper sedation,
  • strict monitoring of serum sodium level,
  • mannitol (strict monitoring!)
36
Q

What is the purpose of MARS in supportive management of acute liver failure?

A

MARS uses albumin dialysis to eliminate inflammatory molecules, but it has no survival benefit.

37
Q

What is the purpose of HepaAssist in supportive management of acute liver failure?

A

HepaAssist uses porcine hepatocytes, but it has no survival benefit.

38
Q

What is the purpose of high-volume plasma exchange in supportive management of acute liver failure?

A

High-volume plasma exchange eliminates toxic molecules and cytokines, by exchanging plasma with fresh frozen plasma

39
Q

What is the most important intervention to improve survival in most severe cases of acute liver failure?

A

Liver transplantation

40
Q

What are the 1- and 5-year survival rates for liver transplantation in severe cases of acute liver failure?

A

The 1- and 5-year survival rates for liver transplantation in severe cases of acute liver failure are 84% and 75%, respectively, which are lower than non-ALF indications.

41
Q

What is the mechanism of action of hepatocyte transplantation?

A

The transplantation of functional hepatocytes to replace damaged or lost liver cells.

42
Q

What are the future directions for treating acute liver failure?

A

Cell transplantation, including hepatocyte and stem cell transplantation, and organ engineering using decellularized 3D extracellular matrix.

43
Q

What are the King’s college criteria for diagnosing paracetamol-induced acute liver failure?

A
  • Arterial pH < 7.3
  • lactate > 3 mmol/L,
  • serum creatinine > 300 μmol/L, or INR > 6.5.
44
Q

What are the King’s college criteria for diagnosing non-paracetamol-induced acute liver failure?

A
  • INR > 6.5
  • or 3 out of the 5 following criteria: aetiology: “indeterminate”, age 40, icterus-HE interval > 7 days, bilirubin > 300 μmol/L, and INR > 3.5.
45
Q

What is donor liver steatosis?

A

Donor liver steatosis refers to the accumulation of fat in the liver of a potential donor, which can increase the risk of complications after liver transplantation.

1. Internal Medicine I (20 decks)

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