[37] Liver Failure Flashcards
What are the categories of causes of acute liver failure?
Infection Toxins Vascular Obstetric Other
What infections can cause acute liver failure?
Hep A/B
Cytomegalovirus
Epstein-Barr Virus
Leptospirosis
What toxins can cause acute liver failure?
EtOH
Paracetamol
Isoniazid
Halothane
What are the vascular causes of acute liver failure?
Budd-Chiari
What are the obstetric causes of acute liver failure?
Eclampsia
Acute fatty liver of pregnancy
What are the signs of acute liver failure?
Jaundice Oedema and ascites Bruising Encephalopathy Fetor hepaticus
How might encephalopathy caused by acute liver failure present?
Aterixis (tremor) Constructional apraxia (inability or difficulty to build, assemble, or draw objects)
How should acute liver failure be investigated?
Bloods
Microbiology
Imaging
What bloods should be done in acute liver failure?
FBC U&E LFT Clotting Glucose ABG Bloods to look for cause
What might be found on FBC in acute liver failure?
Signs of infection
Signs of GI bleed
Decreased MCV
Why might there be a decreased MCV in acute liver failure?
Due to ethanol
What might be found on U&Es in acute liver failure?
Decreased urea and increased creatinine, indicating hepatorenal syndrome
How can LFTs be used to differentiate between EtOH and viral causes of acute liver failure?
AST:ALT > 2 indicates alcohol as the cause
AST:ALT <1 indicates viral as the cause
How can LFTs be used to determine if chronic or acute liver failure?
Albumin is decreased in chronic liver failure
Prothrombin is increased in acute liver failure
What may be found on clotting in acute liver failure?
Increased INR
What may be found on ABG in acute liver failure?
Metabolic acidosis
What tests to determine the cause should be done in acute liver failure?
Ferritin Alpha-1AT Caeruloplasin Antibodies Paracetamol levels
What microbiology tests should be done in acute liver failure?
Hep, CMV, and EBV serology
Blood and urine culture
Ascites MCS and SAAG
What imaging should be done in acute liver failure?
CXR
Abdominal US and portal vein duplex
What is hepatorenal syndrome?
Renal failure in patients with advanced chronic liver failure
What is the pathophysiology of hepatorenal syndrome?
Cirrhosis leads to splanchnic arterial vasodilation, which decreases effective circulatory volume, causing RAS activation and leading to renal arterial vasoconstriction. Persistent underfilling of the renal circulation leads to failure
What are the classifications of hepatorenal syndrome?
Type 1 and 2
What happens in type 1 hepatorenal syndrome?
Rapidly progressive deterioration
What is the prognosis of type 1 hepatorenal syndrome?
Survival <2 weeks
What happens in type 2 hepatorenal syndrome?
Steady deterioration
What is the prognosis of type 2 hepatorenal syndrome?
About 6 months
How is hepatorenal syndrome managed?
IV albumin and splanchnic vasoconstrictors
Haemodialysis as supportive treatment
Liver transplant is treatment of choice
Give an example of a splanchnic vasoconstrictor
Terlipressin
Where should patients with acute liver failure be managed?
ITU
How should acute liver failure be managed?
Management of underlying cause
Good nutrition
Thiamine supplements
Prophylactic PPIs
Why are prophylactic PPIs required in acute liver failure?
Prevent stress ulcers
What monitoring should be done in acute liver failure?
Fluids
Blood
Glucose
How should fluid be monitored in acute liver failure?
Urinary and central venous catheters
How should bloods be monitored in acute liver failure?
Daily FBC, U&E, LFT, INR
How should glucose be monitored in acute liver failure?
1-4 hourly
Should glucose be administered in the management of acute liver failure?
Yes, 10% dextrose IV 1L/12 hours
What are the complications of acute liver failure?
Bleeding Sepsis Ascites Hypoglycaemia Encephalopathy Seizures Cerebral oedema
How can you manage bleeding as complication of acute liver failure?
Vit K
Platelets
FFP
Blood
How can you manage sepsis as a complication of acute liver failure?
Tazocin
Which antibiotic should be avoided in sepssi caused by acute liver failure?
Gentamicin
Why should you avoid gentamicin in acute liver failure?
Nephrotoxic
How can you manage ascites as a complication of liver failure?
Fluid and salt restriction Furosemide Spironolactone Tap Daily weight measurement
How can you manage hypoglycaemia as a complication of liver failure?
Regular BMs
IV glucose if <2mM
How can you manage encephalopathy as a complication of liver failure?
Avoid sedatives
Lactulose, with or without enemas
Rifaximin
How can you manage seizures as a complication of liver failure?
Lorazepam
How can you manage cerebral oedema as a complication of liver failure?
Mannitol
What drugs should be avoided when prescribing in acute liver failure?
Opiates
Oral hypoglycaemics
Na-containing IV fluids
What happens to the effects of warfarin in liver failure?
Increases
What drugs are hepatotoxic?
Paracetamol Methotrexate Isoniazid Salicylates Tetracycline
What are the poor prognostic factors for acute liver failure?
Grade 3/4 hepatic encephalopathy Age >40 years Albumin <30g/L Increased INR Drug-induced liver failure
What are the types of liver transplant?
Cadaveric
Live
What are the types of cadaveric liver transplant?
Heart-beating
Non-heart beating
What part of the liver is transplanted in live transplants?
Right lobe
