FN: Liver Failure

Question 1

Causes

Answer 1

Cirrhosis
Acute:
- 􏰁 Infection: Hep A/B, CMV, EBV, leptospirosis
- 􏰁 Toxin: EtOH, paracetamol, isoniazid, halothane 􏰁 - Vasc: Budd-Chiari
- 􏰁 Other: Wilson’s, AIH
- 􏰁 Obs: eclampsia, acute fatty liver of pregnancy

Question 2

Signs

Answer 2

􏰀 1. Jaundice
􏰀 2. Oedema + ascites
􏰀 3. Bruising
􏰀4.  Encephalopathy
􏰁 Aterixis
􏰁 Constructional apraxia (5-pointed star)
􏰀 5. Fetor hepaticus
6. Signs of cirrhosis / chronic liver disease

Question 3

Ix

Answer 3

• Bloods
• Microbiology
• Radiology

Question 4

Bloods required

Answer 4

1. FBC - infection, GI bleed, reduced MCV (EToH)
2. U&E
   - reduced Urea, increased Creatinine: hepatorenal syndrome
   - Urea synthesis in liver and therefore poor test of renal function
3. LFTs
   - AST”ALT >2= EtOH
   - AST: ALT <1 = Viral
   - Albumin: reduced in chronic liver failure
   - PT: increased in acute liver failure
4. Clotting: increased INR
5. Glucose
6. ABG: metabolic acidosis
7. Causes: Ferritin, alpha1 antitrypsin, caeruloplasmin, Abs, paracetamol levels

Question 5

Microbiology

Answer 5

• hep, CMv, EBV serology
• Blood and urine culture
• Ascites MCS + SAAG

Question 6

Radiology

Answer 6

CXR

Abdo Us + portal vein duplex

Question 7

Hepatorenal syndrome

Answer 7

Renal failure in patients with advanced CLF

- Diagnosis of exclusions

Question 8

Pathophysiology of hepatorenal syndrome

Answer 8

“Underfill theory”
􏰀 Cirrhosis → splanchnic arterial vasodilatation → effective circulatory volume → RAS activation → renal arterial vasoconstriction.
􏰀 Persistent underfilling of renal circulation → failure

Question 9

Classification of hepatorenal syndrome

Answer 9

􏰀 Type 1: rapidly progressive deterioration (survival
<2wks)
􏰀 Type 2: steady deterioration (survival ~6mo)

Question 10

Rx of Hepatorenal syndrome

Answer 10

􏰀 1. IV albumin + splanchnic vasoconstrictors (terlipressin)
􏰀 2. Haemodialysis as supportive Rx
􏰀 3. Liver Tx is Rx of choice

Question 11

Mx of Liver Failure

Answer 11

􏰀 Manage in ITU
􏰀 Rx underlying cause: e.g. NAC in paracetamol OD 􏰀 Good nutrition: e.g. via NGT ̄c high carbs
􏰀 Thiamine supplements
􏰀 Prophylactic PPIs vs. stress ulcers

Question 12

Monitoring of Liver Failure

Answer 12

􏰀 Fluids: urinary and central venous catheters 􏰀 Bloods: daily FBC, U+E, LFT, INR
􏰀 Glucose: 1-4hrly + 10% dextrose IV 1L/12h

Question 13

Complications of Liver Failure

Answer 13

􏰀 1. Bleeding: Vit K, platelets, FFP, blood
􏰀 2. Sepsis: tazocin (avoid gent: nephrotoxicity)
􏰀3. Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt 􏰀 4.Hypoglycaemia: regular BMs, IV glucose if <2mM
􏰀 5. Encephalopathy: avoid sedatives, lactulose ± enemas,
rifaximin
􏰀 6. Seizures: lorazepam
􏰀 Cerebral oedema: mannitol

Question 14

Prescribing in Liver failure

Answer 14

􏰀 Avoid: opiates, oral hypoglycaemics, Na-containing IVI 􏰀 Warfarin effects ↑
􏰀 Hepatotoxic drugs: paracetamol, methotrexate,
isoniazid, salicylates, tetracycline

Question 15

Poor prognostic factors

Answer 15

􏰀 - Grade 3/4 hepatic encephalopathy
- 􏰀 Age >40yrs
􏰀-  Albumin <30g/L
- 􏰀 ↑INR
- 􏰀 Drug-induced liver failure

Question 16

Lover Transplant types

Answer 16

􏰀 Cadaveric: heart-beating or non-heart beating
􏰀 Live: right lobe􏰀 Cadaveric: heart-beating or non-heart beating
􏰀 Live: right lobe

Question 17

Criteria for paracetamol liver injry

Answer 17

Kings College Hospital Criteria in Acute Failure

Question 18

Kings College Hospita criteria in paracetamol induced acute liver failure

Answer 18

pH< 7.3 24h after ingestion
Or all of:
PT > 100s
Cr > 300uM
Grade 3/4 encephalopathy

Question 19

Kings college hospital criteria in non-paracetamol acute liver failure

Answer 19

PT > 100s

Or 3 out of 5 of:
Drug-induced
Age <10 or >40
>1wk from jaundice to encephalopathy
PT > 50s
BR ≥ 300uM