Acute and Chronic Liver Failure Flashcards
In liver failure, the liver loses it ability to…
regenerate / repair
In acute liver failure, liver injury is accompanied with (3 things) in a patient with a previously normal liver
HE
Jaundice
Coagulopathy
(ascites)
What is HE?
Hepatic encephalopathy
Impairment of brain function, associated with cirrhosis. Caused by elevated levels of ammonia in the blood.
What are symptoms of HE?
Changes in personality or behaviour
Impaired motor skill
Altered sleep patterns
Speech and writing changes
Fluctuations in consciousness
What defines coagulopathy?
An INR over 1.5
What is Fulminant liver failure?
aka Acute liver failure:
Rare syndrome of massive hepatocyte necrosis.
Histologically, multiacinar necrosis.
Develops within days to weeks
What classifies fulminant liver disease as hyperacute?
HE develops within 7 days of jaundice
What classifies fulminant liver disease as acute?
HE develops within 8-28 days of jaundice
What classifies fulminant liver disease as subacute?
HE develops within 5-26 weeks
What is the most common cause of fulminant liver failure?
Paracetamol overdose
What is the term used for an abrupt decline in patient with chronic liver failure symptoms?
Acute on chronic liver failure
What is chronic liver failure?
Patient with a progressive history of liver disease
Hepatitis leads to…
fibrosis
Fibrosis of the liver leads to…
Compensated cirrhosis
Compensated cirrhosis can progress to…
Uncompensated cirrhosis (ESLF)
What does ESLF stand for?
End Stage Liver Failure
What are some causes of fulminant liver failure?
Hepatitis A, B or E
CMV
EBV
Autoimmune hepatitis
Paracetamol, alcohol, ecstasy
HCC (hepatocellular carcinoma)
Wilson’s
Haemochromatosis
A1ATD
Budd Chiari
What is Haemochromatosis?
Hereditary disorder, increased absorption of iron leading to gradual accumulation of iron in organs and tissues. Organ damage.
Symptoms include fatigue, joint pain, abdominal pain and hepatomegaly.
What is A1ATD?
Alpha-1 Antitrypsin Deficiency
Genetic disorder of abnormal or insufficient A1AT which normally protects lungs from damage by enzymes released by immune cells.
build up of A1ATD in liver can cause cirrhosis
What is Budd Chiari?
Rare disorder characterised by obstruction or blockage of the hepatic veins that drain the liver causing congestion and liver damage. Often presents with ascites, hepatomegaly and jaundice.
What are the 3 main symptoms of Fulminant liver disease?
Jaundice
Coagulopathy
HE
What is used to grade the HE?
West Haven criteria, grades 1-4
What is grade 1 HE?
Altered mood
Sleep issues
What is grade 2 HE?
Lethargy
Mild confusion
Asterixis (aka liver flap, neurological involuntary flapping of hands)
What is grade 3 HE?
Marked confusion
Somnolent (drowsy, very quiet)
What is grade 4 HE?
Comatose
What symptoms may be seen in acute liver failure but more likely in chronic liver failure?
Spider naevi
Fetor hepaticus
Caput medusae
Dupuytren’s contracture
What is spider naevi?
Small dilated blood vessel near surface of skin, red or blue vascular lesions with central arteriole surrounded by smaller capillaries. Commonly found on face, neck, upper chest and arms.
Caused by changes in blood flow and increased levels of oestrogen
What is fetor hepaticus?
Distinctive musty, sweet or slightly faecal odour of breath associated with severe liver disease due to liver’s inability to detoxify harmful substances.
What is caput medusae?
Appearance of dilated and engorged veins that radiate from the umbilicus outward across the abdomen. Looks like Medusa.
Caused by increased pressure in portal venous system so collateral vessels used.
What is Dupuytren’s contracture?
One or more finger bend towards palm and can’t straighten properly. Thickened and tightened palmar fascia with nodules and fibrous chords forming, pulling fingers bent.
How do you diagnose fulminant liver disease?
LFTs:
Raised bilirubin
Lowered albumin
Raised PT/INR
Raised serum AST and ALT
Raised NH3
Lowered glucose
If paracetamol overdose then raised paracetamol
Imaging:
EEG (electroencephalogram) to grade HE
Abdominal USS (ultrasound scan) to check Budd Chiari
Microbiology:
To rule out infections (blood culture, urine culture and ascetic tap)
Why are there lower glucose levels in liver disease?
Impaired glycogen storage and release
Decreased gluconeogenesis
Altered levels of insulin and glucagon
Where is glucagon made?
Alpha cells of islets of Langerhans in the pancreas
Where is insulin made?
Beta cells of islets of Langerhans in the pancreas
How do you treat fulminant liver disease?
ITU
Remember ABCDE
Give fluids
Analgesia
Treat underlying cause and complications
What do you give for a paracetamol overdose?
Activated charcoal then N acetyl cysteine (NAC)
The charcoal can help to absorb the paracetamol in the stomach preventing it absorption into the bloodstream
NAC works by replenishing deplete glutathione, a substance in the liver that helps to detoxify paracetamol.
How do you treat increased ICP (intra-cranial pressure)?
Mannitol by IV
How do you treat HE?
Lactulose (helps increase ammonia excretion)
How do you treat ascites?
Diuretics (especially spironolactone)
How do you treat a haemorrhage?
Vitamin K
How do you treat sepsis?
Sepsis 6:
High flow oxygen
Obtain blood cultures
IV antibiotics
IV fluids
Measure serum lactate
Monitor urine output
Chronic liver failure is a progressive liver disease over _ months due to repeated liver insults
6
What causes chronic liver failure?
Alcoholic liver disease (most common)
Non-alcoholic fatty liver disease
Viral eg hepatitis B, C or D
also metabolic, budd chiari, drugs, autoimmune, PBC and PSC
What does PBC stand for?
Primary Biliary cirrhosis
What does PSC stand for?
Primary sclerosing cholangitis
What are risk factors for chronic liver disease?
Alcohol
Obesity
T2DM
Drugs
Inherited metabolic disease
Existing autoimmunity
What is used to assess the prognosis and extent of treatment required for chronic liver failure
Child-Pugh Score; A,B or C
Looking at bilirubin levels, ascites presence, serum albumin, PT/INR and hepatic encephalopathy
What is class A chronic liver failure?
100% 1 year survival rate
What is class B chronic liver failure?
80% 1 year survival rate
What is class C chronic liver failure?
45% 1 year survival rate
ESLF (decompensated cirrhosis) is a huge risk factor for developing…
Hepatocellular carcinoma (HCC)
What is used to stratify the severity of ESLD for transplant planning?
MELD score
What are symptoms of chronic liver failure?
Jaundice
Ascites
HE
portal hypertension and oesophageal varices
Caput medusae
Spider naevi
Fetor hepaticus
Palmar erythema
Gynecomastia
Clubbing
Dupuytren’s contracture
What is fetor hepaticus?
Characteristic bad breath due to liver failure
What is palmar erythema?
Palms of hands turn red (not swollen, painful or itchy)
What is gynecomastia?
Enlargement of a man’s breasts usually due to hormone imbalance
What is Dupuytren’s contracture?
One or more fingers are bent in towards the palm due to abnormal thickening of tissue
What investigations would be carried out for chronic liver disease?
Liver biopsy (gold standard) - to determine extent. How much fibrosis vs cirrhosis.
LFT
Ultrasound scan
Ascetics tap culture
What is the treatment for chronic liver failure?
Prevent progression:
Less alcohol, lower BMI, avoid drugs
Consider liver transplant (if decompensated)
Manage complications:
HE with lactulose
Ascites with diuretics
Oesophageal varices ruptures
SBP (spontaneous bacterial peritonitis, infection in ascetic fluid)
