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Y4: Gastroenterology > Acute liver failure > Flashcards

Acute liver failure Flashcards

1
Q

What is acute liver failure?

A
  • Rapid progressive deterioration in liver function
  • Encephalopathy is a cardinal feature
  • Onset is 8-21 days
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2
Q

Describe hyperacute liver failure?

A

Onset =<7 days

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3
Q

Describe fulminant liver failure?

A

Severe impairment of liver function in the absence of pre-existing liver disease

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4
Q

Describe subacute liver failure?

A
  • Onset 4-12 weeks
  • Cerebral oedema is uncommon
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5
Q

Describe Chronic liver failure?

A

Liver failure on a background of cirrhosis

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6
Q

Common causes of Acute liver failure?

A
  • Drugs
  • Viral infections
  • Poisons
  • Miscellaneous
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7
Q

Describe the clinical signs of liver disease?

A
  • Hepatic encephalopathy +/- cerebral oedema
  • Weakness, N/V
  • Jaundice
  • Drowsiness -> coma
  • Fetor hepaticus (breath of death, thiols in the lung)
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8
Q

Describe some diagnostic tests for liver failure?

A
  • Toxicology screen on blood and urine
  • Hepatitis virus testing (Hepatitis B core IgM antibody, HBsAg)
  • Caeruloplasmin, serum copper, urinary copper
  • Autoantibodies: ANA. ASMA, LKM, SLA
  • Bilirubin reflects degree of jaundice
  • Aminotransferases will be very high immediately after paracetmol OD
  • US of liver and doppler of hepatic veins
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9
Q

How you treat seizures associated with liver failure?

A

Phenytoin

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10
Q

Describe the treatments for some common complications of liver failure?

A
  • Cerebral oedema:
    • IV mannitol, hyperventilate
  • Ascites:
    • restrict fluid, low salt diet, diuretics
  • Blind infection treatment:
    • ceftriaxone
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11
Q

What indicates a worse prognosis in liver failure?

A
  • Grade III-IV encephalopathy
  • Age >40
  • Albumin <30g/L
  • Raised INR
  • Drug-induced liver failure
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12
Q

Describe prescribing in liver failure?

A
  • Avoid:
    • Drugs that constipate, oral hypoglycaemics, saline containing IVs
  • Warfarin effects are enhanced
  • Hepatotoxic drugs to remember:
    • Paracetamol, methotrexate, isoniazid, azathioprine, phenothiazines, oestrogen, 6-mercaptopurine, salicylates, tetracycline, mitomycin
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13
Q

Describe Hepatic encephalopathy?

A
  • Liver failures => nitrogenous waste (ammonia) builds up in circulation and brain
  • Astrocytes clear the ammonia
    • Through processes which convert glutamate to glutamine
  • Excess glutamine causes fluid shift hence cerebral oedema
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14
Q

Describe the different stages of Hepatic encephalopathy?

A
  • I: Altered mood, sleep disturbance
  • II: Confusion, slurred speech
  • III: Incoherent; liver flap
  • IV: Coma
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15
Q

Describe Hepatorenal syndrome (HRS)?

A
  • Cirrhosis + ascites + renal failure
  • Splanchnic and systemic vasodilation, but renal vasoconstriction
  • May require liver transplant
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16
Q

Types of HRS?

A
  • HRS-1
    • Rapidly, progressive deterioration
      • Median survival <2 weeks
    • Terlipressin resists hypovolaemia. Haemodialysis by be required.
  • HRS-2
    • Steady deterioration
      • Median survival 6 months
    • TIPSS
17
Q

Name a set of criteria that can predict poor outcomes and need for liver transplantation in Acute liver failure?

A

King’s college hospital criteria

18
Q

Most common cause of acute liver failure worldwide?

A

Acute viral hepatitis

19
Q

Most common cause of acute liver failure in the UK?

A

Paracetamol toxicity

20
Q

Drugs which can cause acute liver failure?

A
  • Paracetamol
  • Halothane
  • Anti-TB drugs
  • MDMA
  • Herbal remedies
21
Q

Viral causes of acute liver failure?

A
  • Hepatitis A, B, E (rare)
22
Q

Miscellaneous causes of Acute liver failure?

A
  • Wilson’s disease
  • Acute fatty liver from pregnancy
  • Shock and cardiac failure
  • Budd-Chiari syndrome
  • Leptospirosis
  • Liver metastases
  • Lymphoma

SWAB LLL

23
Q

Describe the clinical grading of hepatic encephalopathy?

A
  • Grade I
    • Poor concentration, slurred speech
  • Grade II
    • Drowsy but rousable, aggressive behavioue
  • Grade III
    • Delirium, sleepy, disorientation
  • Grade IV
    • Unconscious
24
Q

What is the adverse prognostic criteria for Acute liver failure from paracetamol overdose?

A
  • H+ > 50
  • Serum creatinine > 300
      • PT > 100 secs
      • Encephalopathy grade 3 or 4
25
Q

What is the adverse prognostic criteria for Acute liver failure from non-paracetamol causes?

A
  • PT > 100 seconds
  • Factor V level < 15% + encephalopathy 3 or 4
  • Any 3 of the following:
    • Jaundice to encephalopathy time >7 days
    • Age <10 or >40
    • Indeterminate or drug induced causes
    • Bilirubin > 300
    • PT > 50 seconds
26
Q

Complications of Acute liver failure?

A
  • Cerebral oedema
  • Hyoglycaemia
  • Metabolic acidosis
  • Infection (bacterial or fungal)
27
Q

Describe Wilson’s disease?

A
  • Autosomal recessive
  • Excessive copper deposition in tissues
  • Elevated 24h urinary copper excretion
  • Low caeruloplasmin and serum copper
28
Q

Physiology of copper?

A
  • Absorbed in stomach and proximal small intestine
  • Rapidly taken into the liver
    • Stored and incorporated into caeruloplasmin
  • Normal excretion from body in bile
29
Q

Pathophysiology of Wilson’s disease?

A
  • Failure of synthesis of caeruloplasmin
  • Involves mutation of ATP7B gene on chromosome 13
30
Q

Features of Wilson’s disease?

A
  • Episodes of acute hepatitis -> cirrhosis
  • Extrapyramidal features
    • Tremor, parkinsonism, dementia
  • Kayser-Fleischer rings
  • Haemolytic anaemia
  • Renal tubular acidosis
31
Q

Investigations into Wilson’s disease?

A
  • Low serum caeruloplasmin
  • High serum copper
  • High urine copper
    • Measure 24h urinary copper excretion
32
Q

Describe the management of Wilson’s disease?

A
  • Pencillamine
    • Copper binding agent
    • Can be continued throughout pregnancy
  • May require liver transplant
33
Q

Describe Budd-Chiari syndrome?

A
  • Thrombosis of large hepatic veins
  • Associated with haematological disorders
    • eg myelofibrosis, protein C/S deficiencies
  • Hepatic congestion affecting centrilobular areas -> centrilobular fibrosis
34
Q

Clinical features of Budd-chiari?

A
  • Rapid development of:
    • Upper abdominal pain
    • Ascites
    • Tender hepatomegaly
  • Peripheral oedema if IVC involved
  • Cirrhosis and portal HTN in those who survive acute event
35
Q

Investigations into Budd-chiari?

A
  • LFTs
  • Ascitic fluid analysis: high protein in early stages
  • Doppler US
    • Obliteration of hepatic veins
  • CT
    • Enlargement of caudate lobe
  • Liver biopsy
    • Centrilobular congestion with fibrosis
36
Q

Management of Budd-chiari syndrome?

A
  • Thrombolysis w/ streptokinase
  • Followed by heparin and oral anticoagulation
  • Liver transplant
37
Q

Describe Leptospirosis?

A
  • Zoonotic disease
  • Leptospires (motile, thread-like organisms)
  • Enter human house through skin or mucous membranes

Y4: Gastroenterology (14 decks)

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