Acute and Chronic Liver Failure

Question 1

Jaundice

Answer 1

Failure to clear bilirubin, accumulates in blood

Red cells broken down after 3 months, turned over, iron containing haem metabolised and excreted as bilirubin

Question 2

Encephalopathy

Answer 2

Failure to clear gut-derived toxins (NH3)

Colon packed with bacteria, by products into bloodstream

Question 3

Detoxification diseases

Answer 3

Jaundice

Encephalopathy

Question 4

Protein synthesis diseases

Answer 4

• Failure to produce clotting factors= coagulopathy on blood tests
• Failure to produce clotting inhibitors= balance in practice?
• Failure to produce albumin= oedema, impaired binding of drugs

Question 5

Energy storage diseases

Answer 5

Hypoglycaemia

Muscle breakdown

Question 6

Hypoglycaemia

Answer 6

Failure to store or release glucose

Question 7

Muscle breakdown

Answer 7

Failure to utilise carbohydrate

Question 8

Factors of acute vs chronic

Answer 8

 Time scale (<2-3 months vs >2-3 months)
 Different aetiologies
 Different clinical presentations

Question 9

Describe Acute Liver Failure

Answer 9

Rapid onset; no underlying chronic liver disease
 Acute liver injury = high ALT COMMON (an enzyme produced by liver)
 Severe acute liver injury = high ALT
+ jaundice / coagulopathy UNCOMMON
 Acute liver failure = high ALT
+ jaundice / coagulopathy
+ encephalopathy RARE

Question 10

Causes of ALF

Answer 10

-Common= paracetamol
-Less common
=Other drugs
=antibiotics esp. anti-TB meds
=antiepileptics
=herbal remedies
=ecstasy
=Acute viral infections
-hepatitis B (and A, E)
=Autoimmune hepatitis
=Seronegative (non-A to E)= causes extensive necrosis
hepatitis
-Rare
Vascular diseases
=Budd-Chiari
Metabolic diseases
=Wilson’s
=acute fatty liver of
pregnancy
Cancer
Ischaemia
=hypotension
Toxins
=Amanita phalloides
mushroom
=carbon tetrachloride

Question 11

Treatments of Acute Liver Failure (Correction of coagulopathy)

Answer 11

-N-acetyl cysteine infusion
-Vitamin K
=substrate required for certain clotting factor synthesis
(II, VII, IX, X)
=if dietary deficiency, clotting will look worse than liver
function really is, so give
=replacement will not “mask” liver dysfunction
-FFP (fresh frozen plasma)
=blood product containing clotting factors
=replacement will prevent use of clotting times as a
marker of liver function, so try to avoid giving
-Liver transplant unit

Question 12

Prognosis in paracetamol ALF

Answer 12

-Unlikely to recover spontaneously if:
= PT>100 AND
= Anuric / creatinine >300 AND
= Grade 3-4 encephalopathy (stupor/coma)
-Contraindications:
= Alcohol?
= Previous overdoses?
= Depressed?

Question 13

Outcomes of seronegative hepatitis (extensive necrosis of liver)

Answer 13

• Liver regenerates and recovers fully

- Liver fails to regenerate and needs transplant

Question 14

Prognosis in non-paracetamol ALF

Answer 14

 Age (<10 or >40 worse)
 Aetiology (drug/seronegative worse than viral)
 PT >50 or INR >3.5
 Bilirubin >300
 Time from jaundice to encephalopathy <7d
 3 out of 5 = unlikely to recover spontaneously

Question 15

Paracetamol vs non-paracetamol ALF

Answer 15

Paracetamol causes hyper acute liver failure
 Rapid progression of coagulopathy over hours, rather
than days
 Usually encephalopathy in less than 1 week

Other causes usually more gradual onset
 Progression over several weeks

Question 16

General management of ALF

Answer 16

Identify and treat underlying cause
 NAC for paracetamol
 Antivirals for hepatitis B
 Steroids for autoimmune hepatitis

 Supportive care
 Close monitoring (especially paracetamol)
 Liver transplantation if appropriate

Question 17

What is Chronic Liver Failure?

Answer 17

Less well-defined terminology
 “chronic liver failure”
 “decompensated cirrhosis”

Impaired hepatocyte function
 Jaundice
 Coagulopathy
 Low albumin

Question 18

Hepatic Encephalopathy

Answer 18

 Failure of hepatocyte function (NH3 clearance)

 Portosystemic shunting

Question 19

What is Hepatic Encephalopathy triggered by?

Answer 19

• Constipation
• Drugs (opiates, sedatives)
• Dehydration (diuretics)
• Infections
• GI bleeding

Question 20

Ascites

Answer 20

 Low albumin
 Portal hypertension
 Renal hypoperfusion

Question 21

Causes of CLF

Answer 21

Any cause of cirrhosis:
 Alcohol
 Non-alcoholic fatty liver disease
 Hepatitis B or C
 Haemochromatosis
 Wilson’s disease
 Primary biliary cholangitis
 Primary sclerosing cholangitis
 Autoimmune hepatitis

Question 22

Management of CLF

Answer 22

Identify and treat underlying cause
 Abstinence for alcohol (Diazepam)
 Antivirals for hepatitis B/C
 Steroids for autoimmune hepatitis

 No treatment for jaundice
 Low salt diet and diuretics for ascites
 Laxatives and antbiotics for encephalopathy
=Vitamin B supplements (Pabrinex/ thiamine)
=Oesophageal varices treated with beta-blocker to reduce pressure/ risk of bleeding, band ligation

 Liver transplantation if appropriate