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Acute liver failure Flashcards

1
Q

Hyperacute liver failure timescale

A

Encephalopathy within 7 days of onset of jaundice

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2
Q

Acute liver failure time frame

A

8-28 days jaundice o encephalopathy

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3
Q

Subacute liver failure timescale

A

Hepatic encephalopatjy 5-12 weeks after jaundice

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4
Q

Severe acute liver injury vs failure

A

Injury - elevated transferases, prolonged PT and jaundice
NO hepatic encephalopathy

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5
Q

Timescale of chronic liver disease encephalopathy

A

> 28 weeks initial presnetation -> encephalopathy

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6
Q

Presentation and clinical signs chronic liver disease encephalopathy

A

Jaundice, coagulopathy, HE
Portal HPTN
Platelets <150 - hypersplenism
Imaging

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7
Q

Signs of decompensating liver disease

A
  • Jaundice
  • HE
  • Ascites/peripheral oedema
  • Haematemesis or melaena
  • Bruising/bleeding
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8
Q

Full liver screen

A

Viral serology - all heps, CMV, HSV1+2, HIV
Autoantibody screen - AMA (PBC), ASMA/ana (ai HEP), pANCA (PSC)
Immunoglobulins
IgA, IgG, IgM
Ferritin and transferrin sats
Sopper/caeruloplasmin
Alpha1 antitrypsin

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9
Q

What is used to screen for HCC, hpeB+C?

A

Alphfetoprotein

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10
Q

What is elevated IgA ass with

A

NAFLD, ALD

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11
Q

Elevated IgM ass wit

A

PBC

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12
Q

Elevated IgG ass with

A

AI hepatitis

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13
Q

What is US used to identify

A
  • Degree dilatation biliary tree
  • Stones in gallbladder
  • Size, patency and flow of hepatic portal veins
  • Spac occupying lesions >1cm
    NOT good - degree fibrosis, stones in CBD
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14
Q

CT benfits in liver pathology

A
  • Can use contrast eg to highkight hepatic artery
  • Good at charcterising liver lesions eg mets vs abscess vs HCC
  • Identifies vascular problems including bleeding, hepatic artery thrombosis or portal vein thrombosis
  • Complications of biliary and gallbladder disease
  • Bile duct dilatation, intra hepatic BD tumours, pancreatic tumours, level f biliary obstruction
  • Doesnt always visulaise biliary stones
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15
Q

MRI in liver pathology summary

A
  • Blood vessels, ducts, hepatic tissue
  • Diffuse liver disorders
    • Haemochromatosis, NAFLD
  • Assess focal lesions
    • Haemangioma, HCC, metastasis
  • CI - metal implants etc
  • Less of abdomen visible
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16
Q

MRCP summary

A
  • Detailed images of hepatobiliary and pancreatic systems
  • Detailed view of biliary dilatation and intra-ductal stones with up to 95% sensitivity
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17
Q

ERCP what can do, risk

A
  • Endoscopic invasive rocecdure - tissue smapling and therapy, stone removal, dilating ducts, stent placement
  • Diagnosis - cholangiogram
  • High risk - pancreatitis, perforation, bleeding
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18
Q

Liver biospy benefits, risks

A

Targetes or non targeted - lesion or general parenchyma
Diagnsoiss+ assess severity
Bleeding high risk

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19
Q

What approach can use in liver biopsy if high risk bleeding

A

Transjugular approach - avoid puncturing liver capsule

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20
Q

What is definition of acute liver failure

A

No underlying chronic liver disease
Biochemical evidence of liver injury
Impaired liver function
AND hepatic encephalopathy (within 8 weeks of first illness)

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21
Q

Hepatic encephalopathy grade I

A

Conscious level - sleep reversal, restless
Personality - forgetful, agitated, irritable
Neuro - tremor, apraxia, incoordination, impaired handwriting
EEG - Triphasic waves (5Hz)

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22
Q

Grade 2 hepatic encephalopathy

A

Conscious level - lethargy, slowed
Personality - disorientated, loss inhibition, innapropriate behaviour
Neuro signs - asterixis, dysarthria, ataxia, hyporeflexes
EEG - triphasic waves (5Hz)

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23
Q

Grade 3 hepatic encephalopathy

A

Conscious level - sleepy confused
Personality - aggressive, disorientation
Neuro = asterixis, muscular rigidity, extensor planters, hyperreactive reflexes
EEG = triphasic waves (5Hz)

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24
Q

Grade 4 hepatic encepahlopathy features

A

Coma
Decerebrate positioning
EEG - Delta slow waves

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25
Signs of acute liver failure
Raised ALT/transaminitis Acutely deranged LFTs, jaundice, INR >1.5
26
Hyperacute liver failure signs on investigations
Significantly elevated PT Low to mod rise in bilirubin Marked increase INR Rapid progression V severe coagulopathy + jaundice+ IC HPTN
27
Causes of hyperacute liver failure
Paracetamol HAV, HEV Ischaemia
28
Acute liver failure causes
Pregnancy, HBV
29
Subacute liver failure investigations
V high bilirubin Low transaminases less marked or later onset coagulopathy Splenomegaly Causes - drug induced liver injury non paracetamol, indeterminate, hep E
30
Drugs causing acute liver faulure
- paracetemol (most comon in UK) - herbals - Anti-TB - Chemotherapy - Statins - NSAIDs - phenytoin - Carbamazepine - Ecstasy - Flucloxacillin
31
Toxins causing acute liver failure
- Amanita phalloides (mushroom poisonning) - Phosphorous - Other toxins - Wilsons disease - AI - Lymphoma - Malignancy (infiltration typically by breast or lympohoma origin) - HLH
32
Viruses causing acute liver failure
- Hep B, A, E (less frequent CMV, HSV, VZV, dengue) - Hep C does not cause acute liver failure
33
Causes of acute liver failure in pregnancy
- Pre-eclamptic liver rupture - HELLP - Fatty liver of pregnancy
34
Vascular causes of acute liver failure
- Budd chiari syndrome - Thrombosis - Hypoxic hepatitis
35
What increases risk of kidney injury and cerebrak iedena in acute liver injury
ALT in 1000s High lcatate
36
How much paracetamol can be toxic
10-15g
37
Paracetamol toxic metabolite and counteractives
N-acetyl-p-benzoquinoneimine -> - Direct oxidative stress - Mitochondrial dysfunction - Immune reaction in 24-72 hours -> hepatocyte necrosis and apoptosis Glutathione naturally limits toxicity but in large overdoses depleted -> Nacetylcystine produces gluathione
38
What weight halves the maximum paracetamol level that can be taken a day
50 kg >50kg = 4g, under = 2g (500mg per dose)
39
Complications of acute liver failure
- Hypoglycaemia - Lactic acidosis - Loss of hepatocyte metabolic function - Coagulopathy - HE - massive systemic inflam response synrome → - Multi organ failure rapidly
40
Symptoms of paracetamol toxicity <8 hours
Nausea/vomitting Metabolic acidosis Coma if paracetamol >800mg/L
41
Symptoms of paracetamol in 12-36 hours
Usually none occassionally abdo pain, RUQ pain
42
Sympotms 24-72 hours after paracetamol overdse
- hepatic failure, - coagulopathy - deranged LFTs - hypoglycaemia - RUQ pain, jaundice - N+V - renal failure
43
Drugs need to be cautious of for liver induced injury
Anti TB Antibiotics - nitrofurantoin, flucloaxacillin, co-amoxiclav Antiepileptics - phenytoin, valproate NSAIDs Cocaine and MDMA - ishcaemic inury
44
Which virus causes highest mortality in acute liver failure
HBV
45
What investigations do in acute liver failure sus AI cause
IgG and autoantibody screens - ANA and ASMA Esp if female, personal or FH of AI disease Liver biospy required
46
What resolves acute liver failure in pregnancy
Prompt delivery of placenta
47
First line investigations for ALF
Aetiology: - Blood for Paracetamol serum level - Urinary tox screen - Viral serological screen - Hep A, B, E - HBsAg, anti-HBc IgM, HDV if + - anti HAV, HEV IgM - Herpes simplex (anti-HSV IgM) - VZV (PCR + anti IgM) - CMV - EBV - pARVOVIRUS - AI markers - ANA, ASMA, immunoglobulins - Ultrasound - exclude chronic disease
48
6 hrly monitoring in ALF
PT/INR Liver enzymes esp bilirubin, ALT Renal function - urine output, urea, creatinine ABG+lactate Lipase/amylase for pancreatitis as complications
49
How long give N-acetylcysteine for in paracetamol overdose
PT<20 or up to 5 dyas
50
Acute treatment paracetamol overdose
N-acetylcysteine Aggressive fluid resus - 3-4 litres crystalloid first 24 hours glucose infusions if hypo Intubate and ventialte if encephakopathy threat AW Broad spectrum antibiotics and antifungals Intotropes if hypotensive Early CVVH - control acidosis/ammonia Stress ulcer prophylacis
51
What electrolyte disturbances see in ALF
- Hypoglycaemia - Hyponatremia - Hypophosphatemia - Hypokalemia
52
Complications of ALF
Electrolyte and glucose low Renal damage Pulmonary - oedema, ARDS, penumopathy Infetion - septicaemia, pneumonia, UTI Haemodynamic _/- coag/haemosatsis - hyperkinetic sydnrome, arrhythmia, thrombocytopenia and prolonged PT Neuro - cerebral oedema -> intracranial HPTN -> brain death
53
Risk factors for IC HPTN if ALF
Hyperacute failure Renal impariment Need for inotropic support Persistent elevation of arterial ammonia >150-200
54
NAC efficacy
100% effective under 8 hours Drops dramatically with time over 8 hours
55
What to do if side effects from NAC
Anithistamines, slow infusion rate
56
Treatmetn for AI liver failure
Steroids IF no HE Increase risk of sepsis
57
Specific treatments for Hep B and Hep E in ALF
Hep B - nucleotide analogues Hep E - ribavarin
58
Budd chiari syndrome management
TIPS, hepatic vein stenting, thrombolysis
59
Criteria for paracetamol induced ALF for transplant referral
Arterial pH <7.3 or HCO3 <18 INR >3 day 2 or >4 thereafter Oliguria and/or elevated creatinine Altered LOC Hypoglycaemia Elevated lactate unresponsive to fluid resuscitation
60
Non paracetamol criteria for transplant referral ALF
pH <7.3 or HCO3<18 INR >1.8 Oliguria/renal failure ir Na<130mmol/l Encephalopathy, hypoglycaemia or metabolic acidosis Bilirubin >300 umol/l OR 17.6mg/dl Shrinking liver sie
61
Kings college criteria for paracetamol transplant liver after fluid resus
pH<7.3 Lactate >3 Following 3: -HE >grade 3 Serum creatinine >300 INR >6.5
62
Kings college criteria non paracetamol ALF for transplatn
INR >6.5 3/5 of: -Aetiology - indeterminate, hepatitis, DILI -Age <10 years or >40 years Interal jaundice encepahlopathy >7 dyas Bilirubin >300 INR >3.5
63
Medical CIs to liver transplantation
Untreated or progressive infection Extrahepatic or metastatic malignancy Progressive hypotension, resistant or vasopressor support Clinically significant ARDS, Fi02>0.8 Fixed dilated pupils > 1 hours Sev coexistent cardiopulmonary isease HIV AIDS
64
Psychiatrics CIs to transplantation
Multiple episodes self harm >5 Active IV drug abuse or oral polydrug abise Alcohol dependence or abuse Established pattern of non compliance with treatment Consistently stated wished to die Chronic refractory schizophrenia resistant to therapy Incapacitiating dementia or mental retardation

GI, liver, kidney (50 decks)

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