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Gastrointestinal Block > Acute Liver Failure - liver emergencies > Flashcards

Acute Liver Failure - liver emergencies Flashcards

1
Q

Define Acute Liver Failure

How can this be subcatagorised

A

Rapid deterioration of liver function (<26 weeks) with coagulation disorder (INR > 1.5) and encephalopathy without pre-existing cirrhosis

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2
Q

How can acute liver failure be subcatagorised based on duration?

A

Acute liver failure is defined as an Illness <26 weeks

  • Hyperactue (<7 days)
  • Acute (7-21 days)
  • Subacute (21 days to 26 weeks)
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3
Q

What biochemistry changes would be seen in a paracetamol overdose (usually>150mg/kg)

A

Very high ALT/AST ( tens of thousands)

Rapidly rising PT/INR and Bilirubin

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4
Q

Treatments of paracetamol overdose

A
  1. Activated charcoal within 4 hours ingestion
  2. N-acetylcysteine whenever there is ALF and paracetamol
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5
Q

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

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)

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6
Q

Drug Induced Liver Injury (DILI) usally occurs within what timeframe of taking the drugs?

A

Usually within 6 monthes of taking drug

Prescription and non prescription meds

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7
Q

Treatment of ALF due to DILI

A

Transplantation the most effective

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8
Q

Which viral hepatitis does NOT cause acute liver failure?

A

Hepatitis C

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9
Q

What two groups of people are at a higher risk of ALF due to viral Hepatitis?

A
  1. Pregnant women
  2. Immunosuppressed
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10
Q

Treatments for ALF from viral hepatits?

(Incl treatment for each specific cause)

A
  1. Hep A and E – supportive care (Ribavarin for Hep E)
  2. Hep B - Lamivudine, Tenofovir, Entecavir
  3. VZV, HSV - Aciclovir
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11
Q

Why may patients with Wilsons disease present with severe haemolytic anaemia? (10-15%)

A

Due to copper accumulation in RBC

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12
Q

a) ALF biochemistry findings in Wilsons disease?
b) Treatment of ALF in Wilsons disease?

A

a) High Bili, ↓ ALP, Uric Acid
b) Hemofiltration to ↓ copper, very rare to survive without tranplantation

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13
Q

What must you do if you suspect autoimmune hepatitis in a patient presenting with ALF

A

Liver biopsy very important when suspected, as autoantibody negative in 30%

????

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14
Q

Treatment of ALF in autoimmune hepatitis

A

High dose steroids (Prednisilone 40-60mg/day after biopsy if possible)

Transplantation

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15
Q

During what trimester does Acute Fatty Liver of Pregnancy occur?

A

3rd trimester

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16
Q

Biochemistry findings of ‘Acute Fatty Liver of Pregnancy’

(Hint: HELLP)

A

Hamolysis, Elevated Liver enzymes, Low Platelets

  • ↑ ALT -1000
  • ↑ PT
  • ↑ Bilirubin
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17
Q

Treatment of ALF due to Acute Fatty Liver of Pregnancy?

A

Supportive care

Early delivery of foetus

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18
Q

What is Budd Chiari Syndrome?

A

Acute Hepatic Vein Thrombus

Blocks outflow of blood and causes an acute hepatitis. A/w with hyper-coagulable states

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19
Q

How does Budd Chiari Syndrome present? (TRIAD)

A

Abdominal pain, ascites, hepatomegaly

20
Q

a) Classic triad of Budd Chiari Syndrome
b) Treatment of Budd Chiari Syndrome?

A

a) Abdominal pain, Ascites, and Hepatomegaly
b) Vascular stenting, Transplantation

21
Q

List 4 general considerations in a patient with ALF

A
  1. Intensive Care Support
  2. Antibiotics/Antifungals
  3. Coagulopathy correction
  4. Volume/Pressor support
  5. Glucose. Electrolyte monitering
  6. Enteral or parenteral nutrition
22
Q

What is Alcoholic Hepatitis?

Pathophysiology?

A

Parenchymal liver inflammation and hepatocellular damage due to alcohol excess

Apoptosis and necreosis of hepatocytes mediated by T cells and neutrophils?

23
Q

How does alcoholic hepatitis present?

A

Jaundice, malaise, fever, liver failure

24
Q

List 3 investigations findings of Alcoholic Hepatitis

A
  1. Jaundice
  2. AST/ALT ratio >2 (rarely >250)
  3. Prolonged PT
25
Q

List 2 scores to measure prognosis in Alcoholic Hepatitis?

A
  1. Maddrey’s discriminant Function
  2. Glasgow Alcoholic Hepatitis Score (GAHS) - better in predicting benefit from steroid therapy
26
Q

Treatment for Alcoholic Hepatitis and why

A
  1. Withdrawl symptoms: Benzodiazepines, Parenteral Thiamine, B vitamins
  2. Sepsis in 25-50%- full septic screen
  3. Fluid support - mainly for AKI
  4. Nutrition - maintain gut integrity and prevent translocation of bacteria
  5. Prednisolone 30-40mg
27
Q

What is Hepatorenal Syndrome?

A

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

28
Q

Criteria for Hepatorenal Syndrome?

A
  • 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)
29
Q

What is Type 1 Hepatorenal Syndrome

A

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

30
Q

What is Type 2 Hepatorenal Syndrome

A

Stable , less progressive impairment (median survival – 6 monthes)

May develop Type 1 at any time

31
Q

Pathophysiology of Hepatorenal Syndrome

A
  1. Splanchnic vasodilatation and reduced MAP
  2. activation of SNS and RAAS + renal vasoconstriction
  3. Impaired CO due to cardiomyopathy
  4. Vasoactive compunds impairing glomerular microcirculatory haemodynamics (endothelin-1, thromboxane A2, Leukotrienes)
32
Q

Treatment of Hepatorenal Syndrome?

A
  1. Terlipressin
  2. 20% Albumin (volume expansion)
  3. TIPS
33
Q

What is Spontaneous Bacterial Peritonitis?

What is the cause?

A

Spontaneous infection of ascitic fluid without an apparent source

Possibly due to translocation of gut bacteria

34
Q

Most common organisms in Spontaneous Bacterial Peritonitis

A

Gram negative aerobes ie. E.coli

35
Q

Clinical features of Spontaneous Bacterial Peritonitis

A
  1. Fever
  2. Nausea and Vomitting
  3. Malaise
  4. Abdominal pain (50% are pain free)
  5. Encephalopathy
  6. GI bleeding
  7. Worsening LFTs
36
Q

How is Spontaneous Bacterial Peritonitis diagnosed?

A
  1. Ascitic fluid sample >250 PMNs/uL
  2. Ascitic fluid culture
37
Q

Management of Spontaneous Bacterial Peritonitis

A
  1. IV Cefotaxime
  2. IV Albumin
  3. Prophylactic Norfloxacin (longterm)

Recheck ascitic fluid WCC after 48 hours, If not ↓, consider resistant organisms

38
Q

What is Acute Cholecystitis?

What is the most common cause?

A

Acute inflammation of the gallbladder wall and often due to obstruction of the cystic duct

Most commonly due to stones (90%), but 10% acalculous

39
Q

List 4 clinical features of Acute Cholecystitis

A
  1. Murphy’s sign
  2. Fever
  3. Nausea and vomiting
  4. Peritonitis
40
Q

What is Murphy’s sign

A

Sign of acute cholecystitis → right hypochondrial pain worse on inspiration

41
Q

List 4 investigations for Acute Cholecystitis

A
  1. Leukocytosis, ↑ CRP
  2. ↑ALP and Bilirubin (if stones in the CBD)
  3. USS – Thickened wall, pericholecystic fluid, distended, sludge/stones
  4. CT if perforation suspected + surgical review
42
Q

Treatment for Acute Cholecystitis

A

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)

43
Q

What is Cholangitis?

Mot common cause?

A

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

44
Q

List the 3 key clinical signs of Cholangitis and state the name given to this triad?

A

Charcots triad: Fever, RUQ pain, jaundice (70% of patients)

(Gram negative sepsis in the elderly)

45
Q

Treatment of Cholangitis?

A
  1. Fluid resuscitation
  2. IV antibiotics – cover gram (-)
  3. Decompress bile ducts - ERCP + Sphinctorotomy +/- stent

Gastrointestinal Block (26 decks)

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