Acute Liver Disease & Fulminant Hepatic Failure

Question 1

Give some examples of the main functions of the liver?

Answer 1

Metabolism of:
- Protein, Carbohydrate, Lipid, Bile acid, Bilirubin

• Hormone and Drug metabolism
• Immunological defence

Question 2

What are the 3 true Liver Function Tests?

Answer 2

Bilirubin
Albumin
Prothrombin time

Question 3

What other tests are often carried out and clustered under the heading of “LFT’s”

Answer 3

ALT/AST
Alkaline Phosphatase (ALP)
GGT

Question 4

What are the main clinical features of acute liver disease?

Answer 4

• None (pt may be asymptomatic)
• Jaundice
• Lethargy
• Nausea
• Anorexia
• Pain
• Itch
• Arthralgia
• ABNORMAL LFTs

Question 5

What can commonly cause Acute Liver Disease?

Answer 5

• Viral => Hep (A-E), CMV, EBV
• Drugs (paracetamol)
• Cholangitis
• Alcohol
• Malignancy

Question 6

What rare causes may result in acute liver disease?

Answer 6

• Budd Chiari
• Acute fatty liver of pregnancy (AFLP)
• Cholestasis of Pregnancy

Question 7

What investigations are used in acute liver disease?

Answer 7

• LFT’S (including Albumin & Bilirubin)
• Prothrombin time
• US including vascular
• Virology
• RARELY liver biopsy

Question 8

What should you make a point of asking about in an acute liver disease history?

Answer 8

• Drugs including over the counter, herbal and “food supplements”
• Any Possible toxins
• Ask more about Alcohol Hx (i.e. Go beyond “None”)

Question 9

How is acute liver failure treated?

Answer 9

• Rest (may take 3-6 months)
• Fluids, NO alcohol
• Increase calories (high fat foods poorly tolerated)
• If itch – sodium bicarbonate bath, cholestyramine or Ursodeoxycholic acid

Question 10

What electrolytes should be monitored and supplemented in patients with acute liver disease?

Answer 10

• K, PO4 and Mg

- Also look out for Hypoglycaemia as this is a very serious clinical sign

Question 11

Patients with acute liver disease are usually HYPERmetabolic (i.e using more energy than normal) TRUE/FALSE?

Answer 11

TRUE

=> if patients have a poor appetite because of their illness, this may not meet their nutritional requirements

Question 12

What is meant by fulminant hepatic failure?

Answer 12

• Acute episode of severe liver dysfunction
• jaundice and encephalopathy
• Occurs in a patient with a previous normal liver

Question 13

What are the common causes of fulminant hepatic failure?

Answer 13

• Paracetamol
• Viral (Hep B more than other subtypes)
• Drugs

Question 14

What are the rarer causes of fulminant hepatic failure?

Answer 14

• Acute Fatty Liver of Pregnancy
• Mushrooms
• Malignancy
• Wilsons
• Budd Chiari
• Hep A

Question 15

Describe the difference in aetiology of fulminant hepatic failure between the Western and Eastern parts of the world?

Answer 15

Western world (UK/USA)
- Paracetamol = leading cause

Eastern World (Bangladesh, Japan, India)
- Hepatitis Infection = leading cause

Question 16

What complications can result from fulminant hepatic failure?

Answer 16

• Encephalopathy
• Hypoglycaemia
• Coagulopathy
• Circulatory failure
• Renal failure
• Infection

Question 17

How is Fulminant hepatic failure treated?

Answer 17

• Supportive
• Inotropes & Fluids
• Renal replacement
• Management of raised ICP

Question 18

What is the percentage chance of survival after a patient with fulminant hepatic failure receives a lover transplant?

Answer 18

65%

- however need to be on lifelong immunosuppression

Question 19

If a patient has developed Fulminant Hepatic Failure due to paracetamol overdose, what criteria may indicate they should receive a “super-urgent” transplant?

Answer 19

• pH <7.25 after resuscitation
• PT >100 (INR 6.5)
• Creatinine >300 or anuria
• Lactate >3.5 >24h after ingestion

Question 20

If a patient has developed non-paracetamol related Fulminant Hepatic Failure, what criteria may indicate they should receive a “super-urgent” transplant?

Answer 20

• PT >100 or INR >6.5
• Bilirubin >300
• Jaundice to encephalopathy >7 days
• Wilson’s or Budd-Chiari