Acute Liver Failure Flashcards
Definition
Rapid decline in hepatic function + characterised by jaundice, coagulopathy (>1.5), + hepatic encephalopathy in patient with previously normal liver
Acute-on-chronic
Sudden decline in liver function in Px who already has CFL
Chronic liver failure +
Stages of liver disease
Progressive deterioration of liver function of >6 months
Hepatitis -> Fibrosis -> Compensated Liver -> Decompensated cirrhosis
Epidemiology
Alcohol abuse
Age > 40
Female gender
Risk factors
Poor nutritional status
Pregnancy
Chronic hep B
Excess paracetamol ingestion
Aetiology
Infectious:
- Viral hepatitis - A,B,E, CMV
Autoimmune hepatitis
Drugs:
- Paracetamol OD, Halothane, Isoniazid, Ecstasy, Alcohol
Budd-Chiari syndrome
HCC
Metabolic:
- Wilsons, Hemochromatosis, A1ATD
What is Fulminant liver failure?
Severe acute liver failure in Px with no pre-existing liver disease, with encephalopathy developing within weeks of first manifestation of liver disease. Massive hepatocyte necrosis (multiacinar)
ALF can be defined based on the time between the time of onset of jaundice and development of hepatic encephalopathy:
- Hyperacute = > 7 days
- Acute = 8-28 days
- Sub-acute = 29 days - 12 weeks
There is a decreasing risk of cerebral oedema as onset of encephalopathy is increasingly delayed
What is hepatic encephalopathy
When liver doesn’t work properly = toxins (ammonia) builds up in the blood and can travel to the brain
Astrocytes clear it by converting glutamate to glutamine. This leads to influx of fluid into brain via osmosis = cerebral oedema
Signs
Jaundice
Hepatic encephalopathy:
- Confusion, insomnia, inappropriate behaviour
Signs of cerebral oedema:
- abnormal pupillary reflexes, muscular rigidity
Asterixis: if you as patient to extend their wrist it will tremor (LIVER FLAP)
Apraxia = cant copy a 5 pointed start
RUQ tenderness
Symptoms
Chronic pain: risk of paracetamol toxicity
Abdominal pain
Nausea and vomiting
Confusion
West Haven Criteria Grade 1-4
West Haven Criteria Grade 1-4
Grade 1: Altered mood, sleep issues, sleep disturbances, dyspraxia
Grade 2: Lethargy, mild confusion, ASTERIXIS (liver flap)
Grade 3: Marked confusion, incoherent, restlessness, somnolent (v. quiet)
Grade 4: Comatose
Diagnosis
Bloods
- Leukocytes (infection), ABG (metabolic acidosis = paracetamol OD)
LFTs
- Raised bilirubin, albumin, PT/INR (>1.5)
- Aminotransferases = leak into blood when hepatocytes are damaged = AST, ALT
- Raised NH3
- Decreased glucose
Imaging
- EEG (hepatic encephalopathy)
- USS abdomen to check Budd Chiari
Treatment
ITU support: intubation, ventilation, blood glucose
Monitor electrolytes
Consider liver transplant
Treat cause and complications
Paracetamol overdose
N-acetylcysteine
Viral hepatitis
Aciclovir
