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acute liver failure Flashcards

1
Q

what is acute liver failure?

A

clinical condition characterised by biochemical evidence of liver injury/damage (raised ALT), impaired liver function (long PT, high billi), and hepatic encephalopathy setting in <8w (subacute <28w) of the first symptoms, in the absence of pre-existing liver disease.

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2
Q

what is it called if a patient has all the features of acute liver failure but no hepatic encephelopathy?

A

acute liver injury (ALI)

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3
Q

what are the early signs of hepatic encephalopathy (HE)?

A

irritability
lack of coordination

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4
Q

how is HE graded?

A

grades 1-4: 1=most mild, 4=comatose

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5
Q

what are the consciousness levels of each stage of HE?

A

1-sleep reversal, restless
2-lethargy, slowing
3-sleepy, confused
4-comatose

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6
Q

how does the patient act in each stage of HE?

A

1-forgetful, agitated, irritable
2-disorientated, loss of inhibition, inappropriate behaviour
3-disorientation, aggression
4-comatose

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7
Q

what are the neurological signs of each stage of HE?

A

1-tremor, apraxia, impaired coordination, impaired handwriting
2-asterexis, dysarthria, ataxia, hyporeflexia (LMN signs)
3-asterexis, muscular rigidity, extensor plantars, hyperreflexia (UMN signs)
4-decerebration

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8
Q

what is apraxia?

A

loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them and understanding the command.

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9
Q

how does liver injury progress?

A

elevated transaminases due to acute liver insult and asx -> acute liver injury with jaundice, coagulopathy, deranged LFTs -> ALF with all criteria and HE -> multi system failure -> death

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10
Q

what are the classifications of acute, hyperacute, and subacute liver failure?

A

from jaundice to hepatic encephalopathy:
hyperacute =within a week
acute =1-4 weeks
subacute -now accepted up to 28 weeks.

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11
Q

what is an example of a cause of hyperacute liver failure?

A

paracetamol OD

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12
Q

what is an example cause of acute timescale ALF?

A

hep B

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13
Q

what is an example cause of subacute ALF?

A

non paracetamol drug induced liver failure

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14
Q

what are the differences in characteristics between acute hyperacute and subacute liver failure?

A

hyperacute: greater chance of transplant free survival
acute: more jaundiced, moderate chance of transplant free survival
subacute: deeper jaundice, lower transmaminases, less marked coagulopathy, splenomegaly, ascites, shrinking liver volume, extremely poor survival without transplantation

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15
Q

what is the most common cause of ALF worldwide?

A

viruses

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16
Q

what is the most common cause of ALF in the UK?

A

paracetamol overdose

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17
Q

what are the causes of ALF?

A

-drugs
-viral -hep B, A, E (not C!), (CMV, HSV, VZV, dengue -less common)
-toxins -mushroom poisoning, phosphorus
-vascular -budd-chiari syndrome, hypoxic hepatitis
-pregnancy
-wilson disease
-malignant infiltration of liver
-other eg autoimmune, HLH

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18
Q

which drugs can cause ALF?

A

paracetamol
isoniazid
statins
NSAIDs
phenytoin , carbamazepine
cocaine and MDMA
flucloxacillin, nitrofurantoin, co-amox
ketoconazole
some chemo

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19
Q

what malignancies typically can migrate to the liver and cause ALF?

A

breast
lymphoma

20
Q

how do you diagnose non paracetamol drug induced ALF and what do you need to rule out?

A

currently a diagnosis of exclusion
need to especially rule out hep E -hep E IgM should be in acute liver screen

21
Q

why is ruling out hep E important with ALF?

A

hep E if missed will progress to chronic hep E which can lead to cirrhosis if untreated

22
Q

how do cocaine and MDMA cause liver injury and what is the typical presentation and prognosis?

A

induce liver injury via circulatory collapse and hypoperfusion
present with hyperacute ALF
usually will survive on medical management alone but some will need transplants

23
Q

what viral cause of ALF has the highest mortality?

A

hep B

24
Q

what are the subtypes of hep E and which ones cause ALF?

A

1 and 2 cause ALF and they’re associated with travelling to endemic regions eg india
3 and 4 cause chronic hep E esp in immunosuppressed are acquired in the UK

25
Q

which virus +ALF is associated with high mortality during pregnancy?

A

hep E

26
Q

what are the pregnancy related liver diseases?

A

hyperemesis gravidarum
pre-eclampsia, eclampsia, HELLP syndrome
acute fatty liver of pregnancy (AFLP)

27
Q

what happens liver wise in hyperemesis gravidarum?

A

50% get raised transaminases
synthetic liver failure doesn’t occur- doesn’t progress to acute liver injury/failure

28
Q

what can happen to the liver in HELLP syndrome?

A

hepatic ischaemia which as it progresses can result in subcapsular haematomas, parenchymal haemorrhage, hepatic rupture

29
Q

what disease in the foetus is acute fatty liver of pregnancy associated wit?

A

LCHAD deficiency -Long-chain 3-hydroxyacyl-CoA dehydrogenase-stops some fats being able to be broken down causing issues

30
Q

what is budd chiari syndrome?

A

hepatic vein thrombosis

31
Q

when should you consider wilson’s disease in the context of ALF?

A

young patients
low/normal ALP
haemolytic anaemia
possible neuro-psychiatric features

32
Q

how can you divide initial investigations for ALF?

A

-to assess disease severity
-to check aetiology
-to test for complications

33
Q

which initial investigations would you do to assess severity of ALF?

A

-PT -should be checked on admission and 6 hourly therafter
-LFts -should be checked 6 hourly
-U+Es -monitored closely
-ABG and arterial lactate
-arterial ammonia -useful in predicting which patients are at high risk of developing cerebral oedema

34
Q

which initial investigations would you do to check aetiology of ALF?

A

-paracetamol blood level
-urinary toxicology screen
-viral serology screen -hep A, B, E, HSV, VZV, CMV, EBV, parvovirus
-autoimmune screen -liver autoantibodies esp ANA and anti -smooth muscle antibody
-abdo USS -exclude chronic liver disease/cirrhosis

35
Q

what investigations would you do initially check for complications of ALF?

A

lipase or amylase -for pancreatitis

36
Q

what points in the history are really important to add for ALF?

A

HPC: autoimmune sx
PMH: history of suicide attempt, any chance they could be pregnant
DH: ingestion of paracetamol containing compounds, herbal remedies, mushroom ingestion, food supplements, substances all in last 6m, immunosuppression/chemo
SH: travel history

37
Q

what is the initial management for patients with ALF?

A

-transfer to critical care environment
-treat specific cause
-aggressive fluid resuscitation
-correct hypoglycaemia with glucose infusions
-if significant HE, I+V
-avoid hepatotoxic and sedative drugs
-broad spectrum IV abx and antifungals should be given early -they are functionally immunosuppressed
-inotropes if required for BP support
-early RRT if needed for acidosis and raised ammonia

38
Q

which electrolyte disturbances are seen in ALF?

A

low Na+
low phosphate
low K+

39
Q

what biochemical test is a predictor for the development of intracranial HTN in ALF?

A

persistent arterial ammonia >200

40
Q

what are the risk factors for developing intracranial HTN in ALF?

A

hyperacute ALF
young age
renal impairment
high ammonia

41
Q

what is the management technique for hypoxic ALF?

A

circulatory support
transplant rarely indicated or feasible

42
Q

what is the management of ALF/ALI caused by wilson’s disease?

A

if they don’t have HE yet -trial of penicillamine or trientine
if they have HE -transplant only option

43
Q

what is the management of ALF caused by hepatic vein thrombosis ?

A

-TIPSS -transjugular intrahepatic portosystemic shunt-used to connect 2 veins in liver
-hepatic vein stenting
-thrombolysis
-transplant rarely

44
Q

which drug can help in ALF caused by hep E?

A

ribavirin

45
Q

what are the kings college criteria for liver transplant for non paracetamol ALF?

A

-INR >6.5
or 3/5 of:
-Aetiology: indeterminate aetiology, hepatitis, drug-induced hepatitis
-Age <10 years or >40 years
-Interval jaundice encephalopathy >7 days
-Bilirubin >300 µmol/L
-INR >3.5

46
Q

what are the medical contraindications to liver transplantation?

A

-untreated or progressive infection
extrahepatic/metastatic malignancy but case by case
-progressive hypotension resistant to vasopressor support
-ARDS, Fi02>0.8
-fixed dilated pupils for >1 in the absence of thiopentone
-severe coexistent cardiopulmonary disease
-AIDS -case by case basis `

47
Q

what are the psychiatric contraindications to live transplantation?

A

->5 episodes of self harm with established pattern of behaviour
-active IVDU or oral polydrug use
-alcohol dependence/abuse
-established pattern of noncompliance with treatment
-consistently stating wish to die (without mental illness)
-incapacitating dementia or mental retardation
-chronic refractory schizophrenia resistant to therapy

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