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GI, liver, kidney > Acute liver failure > Flashcards

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
Q

Signs of acute liver failure

A

Raised ALT/transaminitis
Acutely deranged LFTs, jaundice, INR >1.5

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26
Q

Hyperacute liver failure signs on investigations

A

Significantly elevated PT
Low to mod rise in bilirubin
Marked increase INR
Rapid progression
V severe coagulopathy + jaundice+ IC HPTN

27
Q

Causes of hyperacute liver failure

A

Paracetamol
HAV, HEV
Ischaemia

28
Q

Acute liver failure causes

A

Pregnancy, HBV

29
Q

Subacute liver failure investigations

A

V high bilirubin
Low transaminases
less marked or later onset coagulopathy
Splenomegaly
Causes - drug induced liver injury non paracetamol, indeterminate, hep E

30
Q

Drugs causing acute liver faulure

A
  • paracetemol (most comon in UK)
  • herbals
  • Anti-TB
  • Chemotherapy
  • Statins
  • NSAIDs
  • phenytoin
  • Carbamazepine
  • Ecstasy
  • Flucloxacillin
31
Q

Toxins causing acute liver failure

A
  • Amanita phalloides (mushroom poisonning)
  • Phosphorous
  • Other toxins
    • Wilsons disease
    • AI
    • Lymphoma
    • Malignancy (infiltration typically by breast or lympohoma origin)
    • HLH
32
Q

Viruses causing acute liver failure

A
  • Hep B, A, E (less frequent CMV, HSV, VZV, dengue)
    • Hep C does not cause acute liver failure
33
Q

Causes of acute liver failure in pregnancy

A
  • Pre-eclamptic liver rupture
  • HELLP
  • Fatty liver of pregnancy
34
Q

Vascular causes of acute liver failure

A
  • Budd chiari syndrome
  • Thrombosis
  • Hypoxic hepatitis
35
Q

What increases risk of kidney injury and cerebrak iedena in acute liver injury

A

ALT in 1000s
High lcatate

36
Q

How much paracetamol can be toxic

A

10-15g

37
Q

Paracetamol toxic metabolite and counteractives

A

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
Q

What weight halves the maximum paracetamol level that can be taken a day

A

50 kg
>50kg = 4g, under = 2g (500mg per dose)

39
Q

Complications of acute liver failure

A
  • Hypoglycaemia
  • Lactic acidosis
  • Loss of hepatocyte metabolic function
  • Coagulopathy
  • HE
  • massive systemic inflam response synrome →
  • Multi organ failure rapidly
40
Q

Symptoms of paracetamol toxicity <8 hours

A

Nausea/vomitting
Metabolic acidosis
Coma if paracetamol >800mg/L

41
Q

Symptoms of paracetamol in 12-36 hours

A

Usually none occassionally abdo pain, RUQ pain

42
Q

Sympotms 24-72 hours after paracetamol overdse

A
  • hepatic failure,
  • coagulopathy
  • deranged LFTs
  • hypoglycaemia
  • RUQ pain, jaundice
  • N+V
  • renal failure
43
Q

Drugs need to be cautious of for liver induced injury

A

Anti TB
Antibiotics - nitrofurantoin, flucloaxacillin, co-amoxiclav
Antiepileptics - phenytoin, valproate
NSAIDs

Cocaine and MDMA - ishcaemic inury

44
Q

Which virus causes highest mortality in acute liver failure

A

HBV

45
Q

What investigations do in acute liver failure sus AI cause

A

IgG and autoantibody screens - ANA and ASMA
Esp if female, personal or FH of AI disease
Liver biospy required

46
Q

What resolves acute liver failure in pregnancy

A

Prompt delivery of placenta

47
Q

First line investigations for ALF

A

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
Q

6 hrly monitoring in ALF

A

PT/INR
Liver enzymes esp bilirubin, ALT
Renal function - urine output, urea, creatinine
ABG+lactate
Lipase/amylase for pancreatitis as complications

49
Q

How long give N-acetylcysteine for in paracetamol overdose

A

PT<20 or up to 5 dyas

50
Q

Acute treatment paracetamol overdose

A

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
Q

What electrolyte disturbances see in ALF

A
  • Hypoglycaemia
  • Hyponatremia
  • Hypophosphatemia
  • Hypokalemia
52
Q

Complications of ALF

A

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
Q

Risk factors for IC HPTN if ALF

A

Hyperacute failure
Renal impariment
Need for inotropic support
Persistent elevation of arterial ammonia >150-200

54
Q

NAC efficacy

A

100% effective under 8 hours
Drops dramatically with time over 8 hours

55
Q

What to do if side effects from NAC

A

Anithistamines, slow infusion rate

56
Q

Treatmetn for AI liver failure

A

Steroids IF no HE
Increase risk of sepsis

57
Q

Specific treatments for Hep B and Hep E in ALF

A

Hep B - nucleotide analogues
Hep E - ribavarin

58
Q

Budd chiari syndrome management

A

TIPS, hepatic vein stenting, thrombolysis

59
Q

Criteria for paracetamol induced ALF for transplant referral

A

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
Q

Non paracetamol criteria for transplant referral ALF

A

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
Q

Kings college criteria for paracetamol transplant liver after fluid resus

A

pH<7.3
Lactate >3
Following 3:
-HE >grade 3
Serum creatinine >300
INR >6.5

62
Q

Kings college criteria non paracetamol ALF for transplatn

A

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
Q

Medical CIs to liver transplantation

A

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
Q

Psychiatrics CIs to transplantation

A

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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