Acute and Chronic Liver Failure

Question 1

How many types of liver injury are there?

Answer 1

2 - Acute and Chronic.

Question 2

Give 5 causes of acute liver disease.

Answer 2

1. Viral hepatitis.
2. Drug induced hepatitis.
3. Alcohol induced hepatitis.
4. Vascular.
5. Obstruction.

Question 3

Name a drug that can cause drug induced liver injury.

Answer 3

1. Amoxicillin (Co-amoxiclav).
2. Flucloxacillin.
3. Erythromyocin.
4. TB drugs.

Question 4

Name 3 drugs that are not known to cause drug induced liver injury.

Answer 4

1. Low dose aspirin.
2. NSAIDS.
3. Beta blockers.
4. HRT.
5. CCB.

Question 5

Drug induced liver injury is common. What question should you remember to ask in a patient history?

Answer 5

Have you started taking any new medication recently?

Question 6

Give 3 symptoms of acute liver disease.

Answer 6

1. Malaise.
2. Lethargy.
3. Anorexia.
4. Jaundice may develop later on.

Question 7

Give 2 possible outcomes of acute liver disease.

Answer 7

1. Recovery.
2. Liver failure.

Question 8

Give 5 causes of chronic liver disease.

Answer 8

1. Alcohol.
2. NAFLD.
3. Viral hepatitis (B, C, E).
4. Autoimmune diseases.
5. Metabolic e.g. haemochromatosis.
6. Vascular e.g. Budd-Chiari.

Question 9

Give 5 signs of chronic liver disease.

Answer 9

1. Ascites.
2. Oedema.
3. Malaise.
4. Anorexia.
5. Bruising.
6. Itching.
7. Clubbing.
8. Palmar erythema.
9. Spider naevi.

Question 10

Give 2 possible outcomes of chronic liver disease.

Answer 10

1. Cirrhosis.
2. Liver failure.

Question 11

Define liver failure.

Answer 11

Liver loses its ability to repair and regenerate leading to decompensation

Question 12

What is acute hepatic failure?

Answer 12

Acute hepatic failure:
* Acute live injury with encephalopathy and deranged coagulation (INR > 1.5) in a patient with a previously normal liver

Question 13

What is acute-on-chronic hepatic failure?

Answer 13

Acute-on-chronic hepatic failure:
* Liver failure as a result of decompensation of chronic liver disease

Question 14

Give 3 causes of liver failure.

Answer 14

1. Infection e.g. viral hepatitis B, C.
2. Induced e.g. alcohol, drug toxicity.
3. Inherited e.g. autoimmune.

Question 15

Name an infective cause of liver failure.

Answer 15

• Hep A,B (and thus D),E but rarely C
• Cytomegalovirus
• EBV
• Yellow fever

Question 16

Name a vascular cause of liver failure.

Answer 16

• Budd-Chiari
• Venous thrombosis

Question 17

What is Budd-Chiari syndrome?

Answer 17

A vascular disease associated with occlusion of hepatic veins that drain the liver.

Question 18

Name a drug cause of liver failure.

Answer 18

• Paracetamol OD
• Halothane (anaesthetic usage)
• Isoniazid (antibiotic)

Question 19

Name a toxin cause of liver failure.

Answer 19

• Carbon tetrachloride
• Mushrooms
• Alcohol
• Paracetamol overdose

Question 20

Name an inherited cause of liver failure.

Answer 20

• Primary biliary cirrhosis (PBC)
• Primary sclerosing cholangitis (PSC)
• Haemachromatosis
• Hepatocellular carcinoma (HCC)
• Autoimmune hepatitis
• Alpha-1-antitrypsin deficiency
• Wilson’s disease

Question 21

What is fulminant hepatic failure?

Answer 21

Clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function.

Question 22

What are the 3 classifications of fulminant hepatic failure?

Answer 22

1. Hyperacute:
   - Encephalopathy within 7 days of jaundice onset
2. Acute:
   - Encephalopathy within 8-28 days of jaundice onset
3. Subacute:
   - within 5-26 weeks

Question 23

Give 4 signs of liver failure.

Answer 23

1. Jaundice
2. Coagulopathy - Abnormal bleeding
3. Hepatic encephalopathy
   
   • Altered mood / dyspraxia
   • Liver flap / Asterixis (flapping tremor)
   • Drowsiness / confusion
4. Fetor hepaticus
   
   • Sweet and musty breath / urine
   • Patient’s breath smells faecal - “rotten eggs +garlic” type
5. Ascites

Question 24

Explain the pathophysiology of hepatic encephalopathy.

Answer 24

A major complication of liver failure:
Liver fails - nitrogenous waste (ammonia) builds up in circulation - liver can’t get rid of it - ammonia crosses the BBB and passes into brain - astrocytes clear it by converting glutamate to glutamine - excess glutamine causes an osmotic imbalance - cerebral oedema

Question 25

Explain why gynaecomastia (breast enlargement) can be a feature of liver failure in males.

Answer 25

Failure of liver to eliminate steroid hormones.

Question 26

Name 3 categories of investigations for liver failure.

Answer 26

1. Bloods 2. Imaging 3. Microbiology

Question 27

Diagnosis: Bloods investigation results for liver failure?

Answer 27

1. Hyperbilirubinaemia - high levels of bilirubin 2. High serum ALT & AST 3. Increased PT 3. Low levels of coagulation factors (low albumin, PT, factor V) 5. Low glucose (since liver is glucose store, in form of glycogen) 6. Ammonia levels high

Question 28

Diagnosis: Imaging - what imaging methods may be useful for liver failure?

Answer 28

1. Electroencephalogram (EEG) = useful in grading encephalopathy 2. Ultrasound = define liver size and may indicate underlying liver pathology 3. CXR 4. Doppler ultrasound = to see hepatic vein patency ('patent' = means open)

Question 29

Diagnosis: Microbiology - which tests for liver failure?

Answer 29

Microbiology - to rule out infection: * Blood culture * Urine culture * Ascitic tap - to check for pathogens

Question 30

Describe the treatment for liver failure.

Answer 30

1. Nutrition. 2. Supplements - calcium, potassium, phosphate etc. 3. Treat cause - Paracetamol OD = give N-ACETYL-CYSTEINE 3. Treat complications - Seizures = Lorazepam - Encephalopathy = Lactulose - Bleeding/Coagulopathy = IV Vitamin K, platelets, blood, fresh frozen plasma (FFP) - Ascites = diuretics - Sepsis = Sepsis 6 pathway - Infection = antibiotics - Ceftriaxone - Hypoglycaemia - IV glucose / dextrose - Signs of raised intracranial pressure / Cerebral oedema = IV Mannitol 4. Prophylaxis against bacterial + fungal infections 5. Reduction of haemorrhage risk - PPI e.g. lansoprazole to reduced GI bleeds 6. Liver transplant.

Question 31

Give 5 symptoms of ruptured varices.

Answer 31

1. Haematemesis. 2. Melaena. 3. Abdominal pain. 4. Dysphagia. 5. Anaemia.

Question 32

What investigation is it important to do in someone with chronic liver disease and ascites? Explain why it is important.

Answer 32

It is important to do an ascitic tap so you can rule out spontaneous bacterial peritonitis as soon as possible.