Liver Failure

Question 1

Liver failure and “mushroom hunter” diagnosis and treatment

Answer 1

Amanita toxicity

tx with charcoal, Pen G, and Silibinin

Question 2

Liver failure, pregnant, high transaminase levels and platelets abnormal

Answer 2

Acute fatty liver of pregnancy/HELLP syndrome

Tx is delivery

Question 3

Liver failure and traveling to HBV endemic area

Answer 3

Hep B infection

Tx entecavir

Question 4

Liver failure and immunocompromised, possible skin vesicles

Answer 4

HSV

Tx acyclovir

Question 5

Liver failure in young patient with ulcerative colitis

Answer 5

Autoimmune hepatitis

Tx steroids

Question 6

Liver failure, kayser fleischer rings

Answer 6

Wilson’s disease

Tx transplant (temporize with plasma exchange)

Question 7

Liver failure and hypercoagulable

Answer 7

Budd Chiari

Tx with anticoagulation and possible TIPS

Question 8

4 differentials for acute liver failure with transaminase levels > 10K

Answer 8

APAP toxicity
Shock liver
Viral infection
Mushroom ingestion

Question 9

Drug given to all acute liver failure patient’s regardless of APAP ingestion

Answer 9

N-acetyl-cysteine

Question 10

4 criteria for diagnosis of acute liver failure

Answer 10

No chronic liver disease
< 26 weeks in onset
INR > 1.5
Encephalopathy

Question 11

Hyperacute liver failure time duration

Answer 11

0-1 week

Question 12

Acute liver failure time duration

Answer 12

1-4 weeks

Question 13

Subacute liver failure time duration

Answer 13

4-26 weeks

Question 14

Staggered vs single dose tylenol ingestion, which has the worse outcome if toxic?

Answer 14

Staggered

Question 15

4 drugs common for causing acute liver failure

Answer 15

INH
Bactrim
Nitrofurantoin
Azoles

Question 16

Seizure drug known for causing acute liver failure

Answer 16

Phenytoin

Question 17

3 common herbals/supplements known for causing acute liver failure

Answer 17

Hydroxycut (phentolamine)
KAVA
Mahuang

Question 18

Preferred method of dialysis in patients with acute liver failure, particularly if ammonia > 200

Answer 18

CRRT > HD

Question 19

Grade 0 hepatic encephalopathy symptoms

Answer 19

None, normal patient

Question 20

Grade 1 hepatic encephalopathy symptoms

Answer 20

Mild confusion, short attention span

Question 21

Grade 2 hepatic encephalopathy symptoms

Answer 21

Disoriented, personality changes, inappropriate behavior

Question 22

Grade 3 hepatic encephalopathy symptoms

Answer 22

Stuporous but arousable

Question 23

Grade 4 hepatic encephalopathy symptoms

Answer 23

Coma

Question 24

Cause of mortality in patient’s with grade 3 and 4 hepatic encephalopathy

Answer 24

Cerebral edema

Question 25

Chronic liver failure drugs that do not work in acute liver failure for hepatic encephalopathy

Answer 25

Lactulose, rifaximin, neomycin (no survival benefit)

Question 26

Map Goal in hepatic encephalopathy for acute liver failure

Answer 26

MAP > 75

Question 27

Osmolality requirement for the use of mannitol in hepatic encephalopathy from acute liver failure

Answer 27

< 320

Question 28

Does therapeutic hypothermia work in acute liver failure for reduction of brain damage from cerebral edema?

Answer 28

No

Question 29

Liver disease severity score for patients with acute vs chronic liver failure

Answer 29

Acute - kings college criteria

Chronic - MELD

Question 30

5 reasons to refer for liver transplant evaluation

Answer 30

Coagulopathy (APAP INR > 3.0 or non-APAP > 1.8)

Acidosis (pH < 7.30, HCO3 < 18, Lactate elevated)

Hypoglycemia

Encephalopathy

Acute kidney injury

Question 31

Typical transaminase profile in patients with acute liver failure due to alcoholic hepatitis

Answer 31

AST > 2x normal but rarely > 400

AST/ALT ratio > 2

Bilirubin > 3

Question 32

Severe alcoholic hepatitis discriminant function threshold

Answer 32

> 32

Question 33

Formula for discriminant function

Answer 33

4.6 x (patient - control PT) + bilirubin

Question 34

When to stop steroids for alcoholic liver failure

Answer 34

After day 7 if no improvement

If they are improving, continue through day 28, then taper

Question 35

Drug that can be used in place of prednisone in alcoholic liver failure

Answer 35

Pentoxifylline

Question 36

Drug class that does not work in alcoholic liver disease

Answer 36

TNF agents

Question 37

2 criteria for SBP diagonsis

Answer 37

Absolute neutrophil count > 250

No organisms on gram stain (if there are, think bowel perf)

Question 38

Treatment for SBP

Answer 38

3rd gen cephalosporin
FQ if PCN allergic
Tx for 5 days

Albumin 1.5 g/kg on day 0, then 1 gm/kg on day 3 (reduces mortality and renal failure)

Question 39

2 things not to do or stop in patients with SBP

Answer 39

Stop non-selective beta blockers

Avoid large volume paracentesis (> 5L)

Question 40

2 medicines to give in hepatic encephalopathy in chronic liver failure

Answer 40

Lactulose and rifaximin

Question 41

Does treating hyponatremia > 120 and no neurologic symptoms help outcomes in chronic liver failure

Answer 41

No

Question 42

Treatment for hyponatremia in chronic liver failure

Answer 42

Free water restriction usually

Hypertonic saline if neurologic symptoms
DON’T give salt tablets or vasopressin medications (mortality increase)

Question 43

Amount of albumin to give in patients after doing paracentesis

Answer 43

After 5L removed, give 5g/L removed

Question 44

Criteria for hepatorenal syndrome in someone with liver failrue

Answer 44

Cr > 1.5 AND

Unchanged after albumin 1g/kg and 2 days off diuretics AND

Absence of nephrotoxic drugs, shock, abnormal urine, or abnormal renal US

Question 45

Difference between type 1 and type 2 hepatorenal syndrome

Answer 45

Type 1 -
Cr doubles over = 2 weeks OR 50% reduced Cr Clearance

Type 2 -
Stable, slower progression than type 1 (months)

Question 46

Map goal in treating hepatorenal syndrome

Answer 46

Map increase 10-15 mmHg