Acute Liver Failure

Question 1

What are the features of liver failure?

Answer 1

Deranged INR

Encephalopathy

Question 2

What time frame divides acute liver failure and chronic liver disease?

Answer 2

Less than 6 months= Acute
> 6 Months = Chronic

Purely acute liver failure occurs without a background of liver failure- acute on chronic is a sudden decompensation in a patient with a background of chronic liver disease

Question 3

What defines hyper-acute liver failure?

Answer 3

Features within seven days

Question 4

What defines acute liver failure?

Answer 4

Features within 7-28 days

Question 5

What defines sub acute liver failure?

Answer 5

Features within 4-26 weeks

Question 6

What are the durations that define acute liver failures actually referring to?

Answer 6

The duration of time from when jaundice first noticed to the development of encephalopathy

Question 7

What is meant by acute on chronic liver failure?

Answer 7

This is the development of acute liver failure, triggered by physiological insult, on a background of chronic liver disease

Patients decompensate- jaundice, ascites, encephalopathy

Question 8

What is the leading cause of acute liver failure?

Answer 8

Paracetamol overdose in the UK

Note- in the East the leading cause is hepatitis

Question 9

What is meant by sero-negative acute liver failure?

Answer 9

Features of acute liver failure (deranged INR + encephalopathy) but no cause is known and there are no indications of autoimmune causes (of currently known antibodies)

Also called Non-A and Non-B

Question 10

What would you expect on the LFTs indicating an acute liver failure?

Answer 10

Massively raised AST and ALT

Question 11

What are some causes of acute liver failure?

Answer 11

Paracetamol
Hepatitis
Ischaemic hepatitis
Seronegative

Question 12

Why is it important to check renal function in patients with acute liver failure?

Answer 12

They’re at risk of developing hepatorenal syndrome

The liver releases vasoactive substances which disrupt the perfusion to the kidneys and can cause renal injury- this can lead to death and mortality is high

Question 13

What blood tests are important markers of liver function?

Answer 13

Albumin

INR

Question 14

What is recommended for fluid resus in acute liver failure? Why?

Answer 14

Colloids are recommended. The liver is being degraded and there is massive release of inflammatory cytokines which causes a massive immune reaction and there is systemic vasodilation. Giving crystalloids can lead to cerebral oedema as they are in a very fluid permeable state.

Question 15

Why is GCS important to check in acute liver failure?

Answer 15

They develop hepatic encephalopathy and cerebral oedema- especially as a complication of fluid resuscitation.

Question 16

What are some features of hepatic encephalopathy?

Answer 16

Drowsiness
Agitation
Aggression
Coma
Asterixis

Question 17

What is asterixis?

Answer 17

The inability to draw a 5 pointed star- it is a test for hepatic encephalopathy but is rarely done. Especially in acute liver failure, it has more use in chronic patients developing hepatic encephalopathy.

Question 18

What can indicate the development of hepatic encephalopathy?

Answer 18

Declining GCS scores
Drowsiness, Agitation, Aggression
Comatose
Hepatic flap

Question 19

What infection cover is needed for patients with acute liver failure?

Answer 19

Antibiotics and Antifungals as bacteremia can occur in upto 80%.

Note- this is still true if the patient is culture negative

Question 20

Why are patients with acute liver failure at a massively increased risk of bacteremia?

Answer 20

Patients are at risk of bacterial and fungal infection and so antifungal and antibacterial cover is needed

This is because the liver is a detoxifying organ that is vital for immune function

Question 21

Why are acute liver failures given PPIs?

Answer 21

They’re at risk of stress ulceration

Question 22

What is given to reduce cerebral oedema?

Answer 22

Mannitol IV

Question 23

Why do the patients with acute liver failure die?

Answer 23

Sepsis
Infection
Multi-organ failure due to hypoperfusion
Cerebral oedema and hepatic encephalopathy

Question 24

What INR defines coagulopathy?

Answer 24

INR>1.5

Question 25

What causes hepatic encephalopathy?

Answer 25

Build up of ammonia, this is eventually causes an osmotic pressure which can precipitate cerebral oedema