Acute Liver Failure - liver emergencies Flashcards
Define Acute Liver Failure
How can this be subcatagorised
Rapid deterioration of liver function (<26 weeks) with coagulation disorder (INR > 1.5) and encephalopathy without pre-existing cirrhosis
How can acute liver failure be subcatagorised based on duration?
Acute liver failure is defined as an Illness <26 weeks
- Hyperactue (<7 days)
- Acute (7-21 days)
- Subacute (21 days to 26 weeks)
What biochemistry changes would be seen in a paracetamol overdose (usually>150mg/kg)
Very high ALT/AST ( tens of thousands)
Rapidly rising PT/INR and Bilirubin
Treatments of paracetamol overdose
- Activated charcoal within 4 hours ingestion
- N-acetylcysteine whenever there is ALF and paracetamol
a) How does mushroom poisoning (amanita phalloide) present?
b) Whar biochemistry changes would you expect to see?
c) Treatment for ALF due to mushroom poisoning
a) Severe GI upset and history of mushroom ingestion
b) Rising PT/INR and Bilirubin
c) Penicllin G and Milk thistle antidotes despite no RCT, Transplantation (most effective)
Drug Induced Liver Injury (DILI) usally occurs within what timeframe of taking the drugs?
Usually within 6 monthes of taking drug
Prescription and non prescription meds
Treatment of ALF due to DILI
Transplantation the most effective
Which viral hepatitis does NOT cause acute liver failure?
Hepatitis C
What two groups of people are at a higher risk of ALF due to viral Hepatitis?
- Pregnant women
- Immunosuppressed
Treatments for ALF from viral hepatits?
(Incl treatment for each specific cause)
- Hep A and E – supportive care (Ribavarin for Hep E)
- Hep B - Lamivudine, Tenofovir, Entecavir
- VZV, HSV - Aciclovir
Why may patients with Wilsons disease present with severe haemolytic anaemia? (10-15%)
Due to copper accumulation in RBC
a) ALF biochemistry findings in Wilsons disease?
b) Treatment of ALF in Wilsons disease?
a) High Bili, ↓ ALP, Uric Acid
b) Hemofiltration to ↓ copper, very rare to survive without tranplantation
What must you do if you suspect autoimmune hepatitis in a patient presenting with ALF
Liver biopsy very important when suspected, as autoantibody negative in 30%
????
Treatment of ALF in autoimmune hepatitis
High dose steroids (Prednisilone 40-60mg/day after biopsy if possible)
Transplantation
During what trimester does Acute Fatty Liver of Pregnancy occur?
3rd trimester
Biochemistry findings of ‘Acute Fatty Liver of Pregnancy’
(Hint: HELLP)
Hamolysis, Elevated Liver enzymes, Low Platelets
- ↑ ALT -1000
- ↑ PT
- ↑ Bilirubin
Treatment of ALF due to Acute Fatty Liver of Pregnancy?
Supportive care
Early delivery of foetus
What is Budd Chiari Syndrome?
Acute Hepatic Vein Thrombus
Blocks outflow of blood and causes an acute hepatitis. A/w with hyper-coagulable states
How does Budd Chiari Syndrome present? (TRIAD)
Abdominal pain, ascites, hepatomegaly
a) Classic triad of Budd Chiari Syndrome
b) Treatment of Budd Chiari Syndrome?
a) Abdominal pain, Ascites, and Hepatomegaly
b) Vascular stenting, Transplantation
List 4 general considerations in a patient with ALF
- Intensive Care Support
- Antibiotics/Antifungals
- Coagulopathy correction
- Volume/Pressor support
- Glucose. Electrolyte monitering
- Enteral or parenteral nutrition
What is Alcoholic Hepatitis?
Pathophysiology?
Parenchymal liver inflammation and hepatocellular damage due to alcohol excess
Apoptosis and necreosis of hepatocytes mediated by T cells and neutrophils?
How does alcoholic hepatitis present?
Jaundice, malaise, fever, liver failure
List 3 investigations findings of Alcoholic Hepatitis
- Jaundice
- AST/ALT ratio >2 (rarely >250)
- Prolonged PT
List 2 scores to measure prognosis in Alcoholic Hepatitis?
- Maddrey’s discriminant Function
- Glasgow Alcoholic Hepatitis Score (GAHS) - better in predicting benefit from steroid therapy
Treatment for Alcoholic Hepatitis and why
- Withdrawl symptoms: Benzodiazepines, Parenteral Thiamine, B vitamins
- Sepsis in 25-50%- full septic screen
- Fluid support - mainly for AKI
- Nutrition - maintain gut integrity and prevent translocation of bacteria
- Prednisolone 30-40mg
What is Hepatorenal Syndrome?
Occurrence of renal failure in a patient with advanced liver disease in the absence of an identifiable cause of renal failure
Type 1 and Type 2
Criteria for Hepatorenal Syndrome?
- Cirrhosis with ascites
- Serum creatinine >133umol/L
- Absence of shock
- Absence of hypovolemia
- No current or recent treatment with nephrotoxic drugs
- Absence of parenchymal renal disease(Proteinuria<0.5g/day)
What is Type 1 Hepatorenal Syndrome
Rapidly progressive (median survival - 2 weeks)
Commonly in alcoholic hepatitis with septic insult such as SBP
Diagnosed when >100% baseline creatinine to a level higher than 221umol/L in <2 weeks
What is Type 2 Hepatorenal Syndrome
Stable , less progressive impairment (median survival – 6 monthes)
May develop Type 1 at any time
Pathophysiology of Hepatorenal Syndrome
- Splanchnic vasodilatation and reduced MAP
- activation of SNS and RAAS + renal vasoconstriction
- Impaired CO due to cardiomyopathy
- Vasoactive compunds impairing glomerular microcirculatory haemodynamics (endothelin-1, thromboxane A2, Leukotrienes)
Treatment of Hepatorenal Syndrome?
- Terlipressin
- 20% Albumin (volume expansion)
- TIPS
What is Spontaneous Bacterial Peritonitis?
What is the cause?
Spontaneous infection of ascitic fluid without an apparent source
Possibly due to translocation of gut bacteria
Most common organisms in Spontaneous Bacterial Peritonitis
Gram negative aerobes ie. E.coli
Clinical features of Spontaneous Bacterial Peritonitis
- Fever
- Nausea and Vomitting
- Malaise
- Abdominal pain (50% are pain free)
- Encephalopathy
- GI bleeding
- Worsening LFTs
How is Spontaneous Bacterial Peritonitis diagnosed?
- Ascitic fluid sample >250 PMNs/uL
- Ascitic fluid culture
Management of Spontaneous Bacterial Peritonitis
- IV Cefotaxime
- IV Albumin
- Prophylactic Norfloxacin (longterm)
Recheck ascitic fluid WCC after 48 hours, If not ↓, consider resistant organisms
What is Acute Cholecystitis?
What is the most common cause?
Acute inflammation of the gallbladder wall and often due to obstruction of the cystic duct
Most commonly due to stones (90%), but 10% acalculous
List 4 clinical features of Acute Cholecystitis
- Murphy’s sign
- Fever
- Nausea and vomiting
- Peritonitis
What is Murphy’s sign
Sign of acute cholecystitis → right hypochondrial pain worse on inspiration
List 4 investigations for Acute Cholecystitis
- Leukocytosis, ↑ CRP
- ↑ALP and Bilirubin (if stones in the CBD)
- USS – Thickened wall, pericholecystic fluid, distended, sludge/stones
- CT if perforation suspected + surgical review
Treatment for Acute Cholecystitis
Should be under surgical team , always check amylase
IV fluids, antibiotics, NBM
MRCP to check for CBD stones
Surgery (in 2-3monthes if better otherwise during admission)
What is Cholangitis?
Mot common cause?
Infection and inflammation of the bile duct usually due to bile duct abnormality
Causes of bile duct abnormalities: Bile duct stones (often CBD), PSC, other strictures – benign or malignant
List the 3 key clinical signs of Cholangitis and state the name given to this triad?
Charcots triad: Fever, RUQ pain, jaundice (70% of patients)
(Gram negative sepsis in the elderly)
Treatment of Cholangitis?
- Fluid resuscitation
- IV antibiotics – cover gram (-)
- Decompress bile ducts - ERCP + Sphinctorotomy +/- stent
