3.14. Liver + Biliary Tree Disease - (Sub)/Fulminant Hepatic Failure

Question 1

What is Fulminant Hepatic Failure?

Answer 1

Severe Hepatic failure, in which (Portosystemic) Encephalopathy develops within 2 weeks, in a patient with a previously normal liver

Question 2

What is Subfulminant Hepatic Failure?

Answer 2

Cases which evolve slower than Fulminant Hepatic Failure, over the course of 2-12 weeks

Question 3

What are the main causes of (Sub)Fulminant Hepatic Failure?

Answer 3

1. Viral Hepatitis
2. Drugs
3. Toxins
4. Miscellaneous Diseases

Question 4

What types of Viral Hepatitis can cause (Sub)Fulminant Hepatic Failure?

Answer 4

1. Hepatitis A
2. Hepatitis B (with/without Hepatitis D)
3. Hepatitis E

Question 5

Which drugs can cause (Sub)Fulminant Hepatic Failure?

Answer 5

1. Analgesics (E.g. Paracetamol Overdose)
2. Monoamine Oxidase Inhibitors
3. Halogenates Anaesthetics
4. Anti-Tuberculosis Medication (E.g. Isoniazide)
5. Anti-Epileptic Medication (E.g. Sodium Valproate)
6. Recreational Drugs (e.g. Ecstacy)

Question 6

What Toxins can cause (Sub)Fulminant Hepatic Failure?

Answer 6

1. Halohydrocarbons

2. Amanita Poisoning

Question 7

What Miscellaneous Diseases can cause (Sub)Fulminant Hepatic Failure?

Answer 7

1. Wilson’s Disease
2. Reye’s Syndrome
3. Acute Fatty Liver of Pregnancy
4. Autoimmune Hepatitis
5. Budd-Chiari Syndrome

Question 8

What is the Pathology of (Sub)Fulminant Hepatic Failure?

Answer 8

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

Question 9

What are the Clinical Features of (Sub)Fulminant Hepatic Failure?

Answer 9

1. Jaundice
2. Small Liver
3. Encephalopathy
4. Fetor Hepaticus
5. Ascites
6. Splenomegaly
7. Cerebral Oedema
8. Infection

Question 10

What type of Jaundice would occur?

Answer 10

Intrahepatic Jaundice

Question 11

Why would the Liver be smaller than usual?

Answer 11

Due to the Necrosis

Question 12

What would Encephalopathy present like?

Answer 12

Decreased Cognitive ability, from Confusion (Grade 1) to a Coma (Grade 4)

Question 13

What is Fetor Hepaticus? And why would it occur?

Answer 13

Sweet Smelling breath, due to the Portal Hypertension

Question 14

What can the associated Cerebral Oedema result in?

Answer 14

Raised Intracranial Pressure and eventually Brain Herniation

Question 15

Why is infection a Clinical Feature?

Answer 15

Due to the patient becoming predisposed to Bacterial / Fungal infection

Question 16

What investigations are required in (Sub)Fulminant Hepatic Failure?

Answer 16

1. Liver Function Test (and Biochemistry)
2. Electroencephalography (EEG)
3. Abdominal Ultrasound

Question 17

What is measured in a Liver Function Test (and Biochemistry)?

Answer 17

Liver Function Test:

1. Serum Albumin
2. Prothrombin Time

Liver Biochemistry:

1. Bilirubin
2. Alkaline Phosphatase (ALP)
3. Gamma-Glutamyl Transpeptidase (G-GT)
4. Aminotransferases:
   a) Aspartate Aminotransferase (AST)
   b) Alanine Aminotransferase (ALT)

Question 18

What is the Liver Function Test (and Biochemistry) looking for?

Answer 18

1. Hyperbilirubinaemia
2. High Serum Aminotransferases (Not useful in the course of the Disease)
3. Low Coagulation Factors (Including Prothrombin Time)

Question 19

What is the purpose of the Electroencephalography (EEG)?

Answer 19

This is used for Grading the Encephalopathy

Question 20

What is the purpose of the Abdominal Ultrasound?

Answer 20

This will define the liver size and determine the Pathology

Question 21

What is the Treatment of (Sub)Fulminant Hepatic Failure?

Answer 21

1. Movement to the Medical Specialties Unit
2. Supportive Therapy
3. Liver Transplantation (Last Resort)

Question 22

Why is the Patient moved to the Medical Specialties Unit?

Answer 22

As there is no Specific Treatment

Question 23

What is included in Supportive Therapy?

Answer 23

Symptomatic Treatment:

1. Raised Intracranial Pressure - I.V. Mannitol
2. Abnormal Electrolyte Levels - 10% Dextrose Infusion and Supplements
3. Coagulopathy - I.V. Vitamin K, plasma and Platelets
4. Prophylaxis against infection
5. Renal / Respiratory Failure - Appropriate Treatment
6. Encephalopathy - Appropriate Treatment (See Encephalopathy Deck)