3.14. Liver + Biliary Tree Disease - (Sub)/Fulminant Hepatic Failure Flashcards
What is Fulminant Hepatic Failure?
Severe Hepatic failure, in which (Portosystemic) Encephalopathy develops within 2 weeks, in a patient with a previously normal liver
What is Subfulminant Hepatic Failure?
Cases which evolve slower than Fulminant Hepatic Failure, over the course of 2-12 weeks
What are the main causes of (Sub)Fulminant Hepatic Failure?
- Viral Hepatitis
- Drugs
- Toxins
- Miscellaneous Diseases
What types of Viral Hepatitis can cause (Sub)Fulminant Hepatic Failure?
- Hepatitis A
- Hepatitis B (with/without Hepatitis D)
- Hepatitis E
Which drugs can cause (Sub)Fulminant Hepatic Failure?
- Analgesics (E.g. Paracetamol Overdose)
- Monoamine Oxidase Inhibitors
- Halogenates Anaesthetics
- Anti-Tuberculosis Medication (E.g. Isoniazide)
- Anti-Epileptic Medication (E.g. Sodium Valproate)
- Recreational Drugs (e.g. Ecstacy)
What Toxins can cause (Sub)Fulminant Hepatic Failure?
- Halohydrocarbons
2. Amanita Poisoning
What Miscellaneous Diseases can cause (Sub)Fulminant Hepatic Failure?
- Wilson’s Disease
- Reye’s Syndrome
- Acute Fatty Liver of Pregnancy
- Autoimmune Hepatitis
- Budd-Chiari Syndrome
What is the Pathology of (Sub)Fulminant Hepatic Failure?
Due to the Aetiology, there is Multi-Acinar necrosis involving a substantial part of the Liver - This can be seen with a Fatty change.in some conditions
What are the Clinical Features of (Sub)Fulminant Hepatic Failure?
- Jaundice
- Small Liver
- Encephalopathy
- Fetor Hepaticus
- Ascites
- Splenomegaly
- Cerebral Oedema
- Infection
What type of Jaundice would occur?
Intrahepatic Jaundice
Why would the Liver be smaller than usual?
Due to the Necrosis
What would Encephalopathy present like?
Decreased Cognitive ability, from Confusion (Grade 1) to a Coma (Grade 4)
What is Fetor Hepaticus? And why would it occur?
Sweet Smelling breath, due to the Portal Hypertension
What can the associated Cerebral Oedema result in?
Raised Intracranial Pressure and eventually Brain Herniation
Why is infection a Clinical Feature?
Due to the patient becoming predisposed to Bacterial / Fungal infection
What investigations are required in (Sub)Fulminant Hepatic Failure?
- Liver Function Test (and Biochemistry)
- Electroencephalography (EEG)
- Abdominal Ultrasound
What is measured in a Liver Function Test (and Biochemistry)?
Liver Function Test:
- Serum Albumin
- Prothrombin Time
Liver Biochemistry:
- Bilirubin
- Alkaline Phosphatase (ALP)
- Gamma-Glutamyl Transpeptidase (G-GT)
- Aminotransferases:
a) Aspartate Aminotransferase (AST)
b) Alanine Aminotransferase (ALT)
What is the Liver Function Test (and Biochemistry) looking for?
- Hyperbilirubinaemia
- High Serum Aminotransferases (Not useful in the course of the Disease)
- Low Coagulation Factors (Including Prothrombin Time)
What is the purpose of the Electroencephalography (EEG)?
This is used for Grading the Encephalopathy
What is the purpose of the Abdominal Ultrasound?
This will define the liver size and determine the Pathology
What is the Treatment of (Sub)Fulminant Hepatic Failure?
- Movement to the Medical Specialties Unit
- Supportive Therapy
- Liver Transplantation (Last Resort)
Why is the Patient moved to the Medical Specialties Unit?
As there is no Specific Treatment
What is included in Supportive Therapy?
Symptomatic Treatment:
- Raised Intracranial Pressure - I.V. Mannitol
- Abnormal Electrolyte Levels - 10% Dextrose Infusion and Supplements
- Coagulopathy - I.V. Vitamin K, plasma and Platelets
- Prophylaxis against infection
- Renal / Respiratory Failure - Appropriate Treatment
- Encephalopathy - Appropriate Treatment (See Encephalopathy Deck)
