chronic liver failure

Question 1

symptoms

Answer 1

ascites
oedema
vommiting blood
malaise
anorexia
muscle wasting - liver needs majority of energy so breaks down muscle to supply it
easy brusing
itching
hepatomegaly

rarer:
jaundice
confusion

Question 2

definition

Answer 2

Progressive liver dysfunction for 6 months or longer - end result of chronic liver disease is cirrhosis which describes irreversible liver remodelling

Question 3

states which can happen after cirrhosis has developed

Answer 3

Compensated - small amount of liver function remains - normal function is able to continue

Decompensated - liver no longer has the capacity to carry out its normal function (if the insult is removed, the liver may be able to recompensate over time to gain back some of its function)

Question 4

whats the decompensated state catagorised by

Answer 4

Coagulopathy - reduced clotting factors

Jaundice - reduced breakdown of bilirubin

Encephalopathy - reduced detoxification of harmful substances

Ascites - due to poor albumin synthesis

GI bleeding - increased portal pressure from varices

Question 5

aetiology

Answer 5

Alcohol
Hepatitis
Inherited conditions - Wilsons
Non-alcohol fatty liver disease
Biliary diseases
Vascular disorders
Medications - drug induced
May be cryptogenic

Question 6

grading system

Answer 6

Child-Pugh score is the grading system for liver cirrhosis
Class A - mild
Class B - moderate
Class C - severe

Question 7

scores for child-pugh system

Answer 7

bilirubin <34. 34-51. >51

albumin >35. 28-35. <28

PT <4. 4-6. >6

encephalopathy none. mild. marked

ascites none. mild. marked

Question 8

risk factors

Answer 8

Modifiable:
Drinking patterns
Obesity

Non-modifiable:
Female sex
Genetic

Question 9

Ascites

Answer 9

Increase intrahepatic resistance
Portal hypertension
Exacerbated by systemic vasodilation, low serum albumin
Systemic vasodilation causes secretion of:
RAAS
Noradrenaline
Vasopressin

Question 10

clinical manifestations

Answer 10

spider naevi, palmar erythema, jaundice, hair loss, leukonychia, asterixis, ascites

abdominal swellings

Question 11

investigations

Answer 11

LFTs - ALT/AST (high, should only be used to support a diagnosis)

(non invasive liver screening)

liver biopsy - gold standard

Question 12

Complications

Answer 12

Hepatic encephalopathy
Ascites
Hyponatraemia
Gastrointestinal bleeding (i.e. variceal bleed)
Bacterial infections (i.e. SBP)
Acute kidney injury
Hepatocellular carcinoma 
Hepatorenal syndrome
Hepatopulmonary syndrome
Acute-on-chronic liver failure

Question 13

management

Answer 13

• prevent progression - lifestyle modifications
• consider transplant
• manage complications:

HE - lachilose
ascites - diuretics
coagulopathy - vitK
rifaxinim - antibiotic
IV mannitol - HE mainly cerebral oedema

Question 14

symptoms specific to chronic liver failure which isn’t found in acute liver failure

Answer 14

• ascites
• splenomegaly
• variceal bleeding
• dilated abdominal wall
• palmar erythema and spider naevi
• mentral irregularities
• testicular atrophy and loss of labido

Question 15

alcohol related liver disease test results

Answer 15

• ↑ AST & ALT (AST:ALT > 1.5:1)
• ↑ GGT (marker of alcohol use)
• ↑ Bilirubin (if cirrhosis or alcoholic hepatitis present)
• ↓ Albumin (in chronic disease)
• ↑ PT/INR (if severe liver dysfunction)

Question 16

non-alcoholic fatty liver disease test results

Answer 16

• Mildly ↑ ALT & AST (ALT > AST, but <5x ULN)
• ↑ ALP (if significant fibrosis or NASH)
• Normal/↑ GGT
• Normal/↓ Albumin (if cirrhosis develops)

Question 17

viral hepititis B+C test results

Answer 17

• ↑ ALT & AST (ALT often > AST)
• ↑ Bilirubin (if cirrhosis or severe damage present)
• Mildly ↑ ALP (if cholestasis in chronic Hep B/C)
• Normal/↓ Albumin (if cirrhosis present)

Question 18

hepatocellular carcinoma test results

Answer 18

• normal/high AST?ALT
• high ALP/GGT
• high bilirubin
• low albumin
• high PT/INR