Liver Failure

Question 1

How does a patient suffering from liver failure present?

Answer 1

• brought to ER (acute)
• jaundice
• altered mental status
• continuous & getting worse
• abdominal pain
• confusion & drowsiness

Question 2

What is significant for diagnosis of liver failure from the patient’s history?

Answer 2

• drugs
• alcohol
• empty paracetamol bottle

Question 3

What will be noticed on physical examination of patient with liver failure?

Answer 3

• hypotension
• tachycardia
• hypoxic
• icteric eyes
• drowsy
• confused
• ascites
• hepatomegaly

Question 4

What is seen in labs of patient with liver failure?

Answer 4

• platelets -> decreased
• AST in thousands -> due to hepatitis or acetominophen toxicity
• PT, PTT, INR -> increased
• ammonia –> very high (in hundreds)

Question 5

What is the definition of liver failure?

Answer 5

rapidly progressive (within 26 weeks) & severe acute liver injury -> impairment of synthetic function & encephalopathy without previous hepatic disease
OR
acute decompensation of chronic liver disease

Question 6

What are the causes of liver failure?

Answer 6

HEPATOTOXIC MEDICATIONS

• acetaminophen (> 4g a day)
• antibiotics (amoxicillin, ciprofloxacin, TMPSMX, nitrofurantoin, doxycycline, dapsone, cephalosporins)
• anti-TB (pyrazinamide)
• anti-convulsants (phenytoin, carbamazepine, valproic acid)

EXOGENOUS TOXINS

• alcohol
• cocaine
• aflatoxin
• herbal supplements & dietary products

INFECTIONS

• Hepatitis A B E or coinfection/superinfection with hepatitis B & D (A B C purely liver)
• CMV (sore throat in daycare)
• EBV

MISCELLANEOUS

• budd-Chiari syndrome
• autoimmune hepatitis
• Wilson’s disease

Question 7

What are the clinical features of liver failure?

Answer 7

• hepatic encephalopathy -> altered mental status, asterixis
• features of underlying etiology -> Kayser-Fleischer rings in Wilson disease
• nausea, vomiting
• fatigue, lethargy, malaise
• jaundice, pruritis
• anorexia
• abdominal pain

Question 8

What are seen in labs of liver failure patients?

Answer 8

• CBC -> thrombocytopenia
• LFTs -> AST & ALT in 1000s -> increased direct bilirubin -> high ammonia
• hypoglycemia
• electrolyte imbalance
• COAGULATION -> elevated INR & PT (INR vitamins)

Question 9

How is liver failure treated?

Answer 9

• liver transplant is the BEST
• if acetaminophen induced failure -> give N-acetylcysteine (NAC)
• if viral -> antiviral
• if autoimmune -> give steroids
• if pregnancy related -> urgent delivery of fetus

Question 10

What is the prognosis of liver failure?

Answer 10

• mortality > 50%

- survival with liver transplant -> 65 - 84% at 1 year