Acute Liver disease and FHF

Question 1

can people with cirrhosis have normal LFTs

Answer 1

yes, 70% do

Question 2

what is acute liver disease

Answer 2

any insult to the liver causing damage with a duration of less than 6 months

Question 3

what does acute liver failure

Answer 3

when damage causes encephalopathy and prolonged coagulation

Question 4

what is wilsons disease

Answer 4

a rare autosomal recessive inherited disorder of copper metabolism that is characterized by excessive deposition of copper in the liver, brain, and other tissues- can be characterised as an ALD

Question 5

what are the clinical features of ALD

Answer 5

none,
jaundice,
lethargy,
nausea,
anorexia,
pain,
itch,
arthralgia,
abnormal LFTs

Question 6

what can cause ALD

Answer 6

viral; hep A-E, CMV, EBV and toxoplasmosis,
drugs,
shock liver (hypotension),
cholangitis,
alcohol,
malignancy,
paracetamol,

rare:
bidd chiari,
AFLP (acute fatty liver in pregnancy),
cholestasis in pregnancy

Question 7

how does cholestasis typically present

Answer 7

RUQ pain, jaundice

Question 8

what is seen in alcohol ALD and why

Answer 8

high bilirubin due to pro inflammatory cytokine response

Question 9

what factors can influence ALD

Answer 9

direct toxicity (of alcohol, virus, drugs, hyperfusion),
nutrition (NASH, malnutrition),
immunological (PBC, AIH),
genetic; (wilsons haemochromatosis)

Question 10

what investigations should be done in ALD

Answer 10

history; - include sexual health (hep E), Symptoms, durations, drugs (OTC, herbal and food suppliments), Possible toxins, alcohol, food from ‘health food shop’ or corner shop (illegal/legal highs), unusual hobbies (free water swimming)

LFTs, PT time,
ultrasound,
virology, 
chronic liver disease investigations,
rare; liver biospy

Question 11

what is the treatment foe ALD

Answer 11

rest 3-6 months, fluids, no alcohol, increase calories (fatty foods poorly tolerated)
to treat itch: sodium bicarbonate bath, cholestyramine or uresodeoxycholic acid

observation for FHF

Question 12

what are the metabolic considerations for ALD

Answer 12

patients in hypermetabolic state- increased requirements
35-40 kcal/kg/day 1.2-1.5 g protein/kg/day

Higher rate of complications in malnourished patients

Oral suppliments/ NG

monitor K, PO and Mg
Hypoglycaemia a concern

Question 13

what drugs cause ALD

Answer 13

can be any:
common inc
Antibiotics; coamoxiclav, flucloxacillin,
NSAIDs
Euphemisms ‘fat burners’ ‘protein powders’
Imported/ no label drugs
Nurofen/ night nurse: contains paracetamol

rare; statins

Question 14

how does paracetamol cause ALD

Answer 14

when metabolises produces NAPQI which is toxic, produces free radical production

Question 15

how is NAPQI combated

Answer 15

with NAC, replenishes glutathione supply which consumes free radicals

Question 16

what gene is associated with paracetamol damage and ALD

Answer 16

P450

Question 17

what is FHF

Answer 17

fulminant hepatic failure; rapid development of jaundice and encephalopathy in a patient with a previously healthy liver

Question 18

what can cause FHF

Answer 18

Paracetamol (overdose)
Fulminal viral (hep E- in elderly or pregnant, HBV, non hep A-E)
Drugs

rare;
AFLP
Mushrooms 
Malignancy 
Wilsons 
Bidd chiari
HAV

Question 19

what are the clinical signs and complications of FHF

Answer 19

Encephalopathy

Hypoglycaemia- used all glycogen in liver, cant regulate

Coagulatory failure

Circulatory failure- hyperdynamic circulatory out put

Renal failure- complicated by circulatory collapse

Question 20

how is FHF treated

Answer 20

Supportive
Inotropes and fluids
Management of raised ICP (intracranial pressure)
Transplant (75% survival, lifelong immunosuppressant, risk of post transplant malignancy)

Question 21

what does the kings college for liver transplant consider

Answer 21

split into paracetamol and non paracetamol

Considers: pH after resus, PT time, lactate, wilsons or bidd chiari, encephalopathy