Gastro

Question 1

How do you define acute liver failure? (What are the criteria?)

Answer 1

Absence of chronic liver disease and

Encephalopathy
Coagulopathy
Jaundice

Question 2

How is acute liver failure sub-categorised based on timing?

Answer 2

Time from onset of jaundice to encephalopathy

<7 days = hyperacute
7-82 days = acute
5-12 weeks = subacute

Question 3

Classify the causes of acute liver failure

Answer 3

Vascular (Ischaemic hepatitis, Budd-Chiari syndrome)
Infective (Viral hepatitis, EBV, CMV, HSV)
Traumatic (Post-surgical)
Iatrogenic: Drugs (paracetamol, antibiotics, anti-epileptics, anti-TB medication, recreational)
Gestational: ALFP, HELLP

Question 4

Why does encephalopathy occur in liver failure?

Answer 4

Ammonia is generated in the gut through the breakdown of amino-acids
It is normally metabolised in the liver to ammonium which is excreted in urine
In ALF, ammonia levels rise and it freely crosses the BBB
It is converted in cells in the brain to glutamine which exerts an oncotic effect, causing raised ICP and death

Question 5

How is hepatic encephalopathy graded?q

Answer 5

West Haven Criteria

I - Trival lack of awareness, euphoria or anxiety, impaired performance of addition
II - Lethargy or apathy, minimal disorientation in time or place, inappropriate behaviour, impaired performance of subtraction

III - Somnolence to semi-stupor, but responsive to verbal stimuli, confusion, gross disorientation
IV - Coma

Question 6

What are specific treatment considerations in ALF?

Answer 6

Supportive - Airway, Invasive monitoring/ vasoactive support (incl. hydrocortisone for functional adrenal insufficiency), RRT and specific antidotes if applicable
For encephalopathy - Removal of ammonia (RRT, lactulose, rifaximin); Cerebral oedema (neuro protective measures)
For coagulopathy - Routine correction not recommended. Consider vitamin K for nutritional replacement
For infection - low threshold for antibiotics
Metabolic - nutritional support/ glucose infusion to prevent hypoglycaemia
Consideration for transplant

NAC - limited to no evidence in support

Question 7

What are the King’s College Criteria for emergency liver transplantation (non-paracetamol overdose)?

Answer 7

INR >6.5/ PT >100s

Or any three of:
PT >50
Non hepatitis A/B
Age <10 or >40
Bil >300
Not hyperacute

Question 8

What are the King’s College Criteria for paracetamol overdose related emergency liver transplantation?

Answer 8

pH <7.3 24h post admission

Or all of:
Grade III or IV encephalopathy
PT >100
Creatinine >300

Or
Lactate >3.5 at 4 hours

Or
Lactate >3 at 12 hours

Question 9

Where is ALT found?

Answer 9

Muscle
Heart
Kidney
Liver

Question 10

What are the LFT features of cholecyststic injury?

Answer 10

ALP >2X upper limit of normal
AND
ALT/ALP ratio <2

Question 11

What are the LFT features of hepatocellular injury?

Answer 11

ALT >3x upper limit of normal and ALT/ALP >5

Question 12

What are the LFT features of hepatocellular injury?

Answer 12

ALT >3x upper limit of normal and ALT/ALP >5

Question 13

What is the severity grading of CDI?

Answer 13

Mild No elevated WCC
Mod WCC <15
Severe WCC >15, Cr >50% baseline, T >38.5

Question 14

What are the Atlanta criteria for pancreatitis?

Answer 14

Mild - no organ failure or complications
Mod - organ failure <48h or local/ systemic complications
Sev - organ failure >48h

Question 15

What are the Ranson criteria?

Answer 15

5 items at admission
5 at 24h

Predictor of mortality

Question 16

What are the Ranson criteria?

Answer 16

5 items at admission
5 at 24h

Predictor of mortality