Acute and Chronic Liver Failure Flashcards
How many types of liver injury are there?
2 - Acute and Chronic.
Give 5 causes of acute liver disease.
- Viral hepatitis.
- Drug induced hepatitis.
- Alcohol induced hepatitis.
- Vascular.
- Obstruction.
Name a drug that can cause drug induced liver injury.
- Amoxicillin (Co-amoxiclav).
- Flucloxacillin.
- Erythromyocin.
- TB drugs.
Name 3 drugs that are not known to cause drug induced liver injury.
- Low dose aspirin.
- NSAIDS.
- Beta blockers.
- HRT.
- CCB.
Drug induced liver injury is common. What question should you remember to ask in a patient history?
Have you started taking any new medication recently?
Give 3 symptoms of acute liver disease.
- Malaise.
- Lethargy.
- Anorexia.
- Jaundice may develop later on.
Give 2 possible outcomes of acute liver disease.
- Recovery.
- Liver failure.
Give 5 causes of chronic liver disease.
- Alcohol.
- NAFLD.
- Viral hepatitis (B, C, E).
- Autoimmune diseases.
- Metabolic e.g. haemochromatosis.
- Vascular e.g. Budd-Chiari.
Give 5 signs of chronic liver disease.
- Ascites.
- Oedema.
- Malaise.
- Anorexia.
- Bruising.
- Itching.
- Clubbing.
- Palmar erythema.
- Spider naevi.
Give 2 possible outcomes of chronic liver disease.
- Cirrhosis.
- Liver failure.
Define liver failure.
Liver loses its ability to repair and regenerate leading to decompensation
What is acute hepatic failure?
Acute hepatic failure:
* Acute live injury with encephalopathy and deranged coagulation (INR > 1.5) in a patient with a previously normal liver
What is acute-on-chronic hepatic failure?
Acute-on-chronic hepatic failure:
* Liver failure as a result of decompensation of chronic liver disease
Give 3 causes of liver failure.
- Infection e.g. viral hepatitis B, C.
- Induced e.g. alcohol, drug toxicity.
- Inherited e.g. autoimmune.
Name an infective cause of liver failure.
- Hep A,B (and thus D),E but rarely C
- Cytomegalovirus
- EBV
- Yellow fever
Name a vascular cause of liver failure.
- Budd-Chiari
- Venous thrombosis
What is Budd-Chiari syndrome?
A vascular disease associated with occlusion of hepatic veins that drain the liver.
Name a drug cause of liver failure.
- Paracetamol OD
- Halothane (anaesthetic usage)
- Isoniazid (antibiotic)
Name a toxin cause of liver failure.
- Carbon tetrachloride
- Mushrooms
- Alcohol
- Paracetamol overdose
Name an inherited cause of liver failure.
- Primary biliary cirrhosis (PBC)
- Primary sclerosing cholangitis (PSC)
- Haemachromatosis
- Hepatocellular carcinoma (HCC)
- Autoimmune hepatitis
- Alpha-1-antitrypsin deficiency
- Wilson’s disease
What is fulminant hepatic failure?
Clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function.
What are the 3 classifications of fulminant hepatic failure?
- Hyperacute:
- Encephalopathy within 7 days of jaundice onset - Acute:
- Encephalopathy within 8-28 days of jaundice onset - Subacute:
- within 5-26 weeks
Give 4 signs of liver failure.
- Jaundice
- Coagulopathy - Abnormal bleeding
- Hepatic encephalopathy
- Altered mood / dyspraxia
- Liver flap / Asterixis (flapping tremor)
- Drowsiness / confusion
- Fetor hepaticus
- Sweet and musty breath / urine
- Patient’s breath smells faecal - “rotten eggs +garlic” type
- Ascites
Explain the pathophysiology of hepatic encephalopathy.
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
Explain why gynaecomastia (breast enlargement) can be a feature of liver failure in males.
Failure of liver to eliminate steroid hormones.
Name 3 categories of investigations for liver failure.
- Bloods
- Imaging
- Microbiology
Diagnosis: Bloods investigation results for liver failure?
- Hyperbilirubinaemia - high levels of bilirubin
- High serum ALT & AST
- Increased PT
- Low levels of coagulation factors (low albumin, PT, factor V)
- Low glucose (since liver is glucose store, in form of glycogen)
- Ammonia levels high
Diagnosis: Imaging - what imaging methods may be useful for liver failure?
- Electroencephalogram (EEG)
= useful in grading encephalopathy - Ultrasound
= define liver size and may indicate underlying liver pathology - CXR
- Doppler ultrasound
= to see hepatic vein patency (‘patent’ = means open)
Diagnosis: Microbiology - which tests for liver failure?
Microbiology - to rule out infection:
* Blood culture
* Urine culture
* Ascitic tap - to check for pathogens
Describe the treatment for liver failure.
- Nutrition.
- Supplements - calcium, potassium, phosphate etc.
- Treat cause
- Paracetamol OD = give N-ACETYL-CYSTEINE - 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 - Prophylaxis against bacterial + fungal infections
- Reduction of haemorrhage risk - PPI e.g. lansoprazole to reduced GI bleeds
- Liver transplant.
Give 5 symptoms of ruptured varices.
- Haematemesis.
- Melaena.
- Abdominal pain.
- Dysphagia.
- Anaemia.
What investigation is it important to do in someone with chronic liver disease and ascites? Explain why it is important.
It is important to do an ascitic tap so you can rule out spontaneous bacterial peritonitis as soon as possible.
