Acute liver failure

Question 1

What are the different types of liver failure by time onset?

Answer 1

Hyperacute - onset less than 7 days ago
Acute - 8-21 days
Subacute - 4-36 weeks
Chronic - on a background of cirrhosis

Question 2

What is liver failure?

Answer 2

The development of encephalopathy and coagulopathy (INR more than 1.5)

Question 3

What is fulminant hepatic failure?

Answer 3

Syndrome resulting from massive necrosis of liver cells leading to failure

Question 4

What are the causes of liver failure?

Answer 4

Alcohol 
NAFLD
PBC
PSC
Haemochromatosis
Autoimmune
Alpha antitrypsin deficiency
Wilson's disease
Malignancy

Viruses:
Viral Hep - B, C, CMV
Yellow Fever
Leptospirosis

Drugs:
Paracetamol overdose
Halothane
Isoniazid

Toxins
Vascular occlusive disease

Question 5

What is CMV?

Answer 5

Cytomegalovirus
Causes chickenpox and cold sores when active
Stays with you forever
Passed on through body fluids of someone in whom it is active
Symptoms when you contract it for the first time include fever, aching, tiredness, nausea, sore throat, swollen glands for about three weeks.

Question 6

What are the signs of liver failure?

Answer 6

Jaundice
Encephalopathy
Fetor hepaticus (sweet breath)
Asterixis (flap)
Constructional apraxia (can’t construct 5 point star)
Signs of chronic liver disease if acute on chronic

Question 7

What bloods do we do in suspected liver failure?

Answer 7

FBC - infection, GI bleed
UE
LFT
Clotting (higher PT and INR)
Glc
Paracetamol
Hep viral screen
CMV and EBV serology
Ferritin
Alpha antitrypsin
Autoantibodies
Caeruloplasmin

Question 8

What is caeruloplasmin for?

Answer 8

Wilson’s disease

Question 9

What cultures do we do in liver failure?

Answer 9

Blood culture
MCS urine
MCS ascites

Question 10

What radiology do we do in liver failure?

Answer 10

USS abdo
CXR
Doppler portal vein (Budd-Chiari syndrome)

Question 11

What is Budd-Chiari syndrome?

Answer 11

Obstruction of the hepatic vein by thrombosis or tumour.

Question 12

What result on the MCS of ascites indicates peritonitis?

Answer 12

Neutrophils above 250

Question 13

What are the complications of liver failure?

Answer 13

Sepsis
Hypoglycaemia
Seizures
Bleeds
Encephalopathy
Ascites
Cerebral oedema

Question 14

Which antibiotics would we give in bacterial peritonitis?

Answer 14

Ceftriaxone 2g /12-24 hours

Ciprofloxacin 200-400mg/12hours

Question 15

What drug do we give in cerebral oedema?

Answer 15

20% Mannitol IV up to 2g/kg over an hour

Repeat 1-2 times after 4-8 hours

Question 16

What do we do for hepatic encephalopathy?

Answer 16

Lactulose 30mg every 1-2 hours to make 3 loose stools a day

Rifaximin - 550mg PO BD

Question 17

What is hepatic encephalopathy?

Answer 17

Encephalopathy due to ammonia and urea build up. Ammonia is removed by astrocytes in the brain and glutamine is made in the process. This glutamine xs causes osmotic imbalance and the fluid moves from circulation into brain cells.

Question 18

What can we do for liver failure?

Answer 18

Monitor and treat the complications

Question 19

What hepatoxic drugs do we avoid in liver failure?

Answer 19

Paracetamol
Methotrexate
Isoniazid
Azathioprine
Oestrogen
Salicylates
Tetracycline
6-mercaptopurine

Question 20

What is the grading of hepatic encephalopathy?

Answer 20

1 - altered mood, sleep disturbance, dyspraxia
2 - drowsiness, confusion, slurred speech, flap, personality change
3 - incoherent, restless, flap, stupor
4 - coma

Question 21

Aside from encephalopathy, what else can cause unconsciousness/drowsiness in liver failure?

Answer 21

Hypoglycaemia
Sepsis
Fits/epilepsy

Question 22

How do we treat the seizures in liver failure?

Answer 22

Phenytoin

Question 23

What is hepatorenal syndrome?

Answer 23

This is cirrhosis, ascites and renal failure.

Other renal causes must have been excluded.

Question 24

What is the patho of HRS?

Answer 24

Abnormal haemodynamics cause vasodilation everywhere aside from vasoconstriction of renal.