Liver Failure

Question 1

What is liver failure?

Answer 1

Liver loses the ability to regenerate or repair, so decompensation occurs
Leads to hepatic encephalopathy, jaundice, ascites + abnormal bleeding

Question 2

How is liver failure classified?

Answer 2

Fulminant hepatic failure (FHF) < 8 weeks of onset of underlying illness.
Subacute FHF: 8-26 weeks.
Chronic decompensated hepatic failure: >6 months.

Question 3

Globally and nationally what accounts for the majority of liver failure cases?

Answer 3

G: Viral infection
N: Paracetemol OD

Question 4

List 4 toxins that can lead to liver failure

Answer 4

Chronic alcohol abuse.
Paracetamol OD
Drug toxicity: some antibiotics, statins, methotrexate
Illicit drugs: ecstasy + cocaine.

Question 5

Give 4 infectious causes of liver failure

Answer 5

Viral hepatitis ABCDE
Adenovirus
Epstein-Barr virus
Cytomegalovirus

Question 6

List 6 less common causes of liver failure

Answer 6

AI hepatitis  
Budd-Chiari syndrome  
Pregnancy-related  
Malignancy 
Wilson's disease  
Haemochromotosis

Question 7

What is the pathogenesis behind jaundice in liver failure?

Answer 7

Decreased ability to conjugate bilirubin + impaired ability to excrete BR

Question 8

What is the pathogenesis behind encephalopathy in liver failure?

Answer 8

Nitrogenous products (e.g. ammonia) absorbed in the gut + goes via the portal circulation to the liver
Healthy liver: extracts these harmful substances
Failure: toxic products go through the liver, reach the brain + exert effects

Question 9

What is the pathogenesis behind coagulopathy in liver failure?

Answer 9

Reduced synthesis of clotting factors
Reduced platelets
Platelet functional abnormalities associated with jaundice or renal failure

Question 10

Give 4 features of symptoms in liver failure

Answer 10

May be asymptomatic
Drowsiness/ confusion
Fever
Nausea

Question 11

Give 6 signs of liver failure

Answer 11

Jaundice (not always)
Hyperdynamic circulation may mimic septic shock.
Abdominal distension + masses
Cerebral oedema with raised ICP: papilloedema, HTN + bradycardia.
Palmar erythema
Asterixis

Question 12

Describe what may be seen in bloods in liver failure considering FBC, INR, AST, ALT, ALP, BR + NH3

Answer 12

FBC: IDA picture + thrombocytopenia.
INR raised
Transaminases very markedly raised but 
ALP slightly high or normal.
BR raised.
NH3 high

Question 13

List 5 tests that may help identify the cause of liver failure

Answer 13

Viral serology  
Paracetamol levels  
Autoantibodies (e.g. ASM, Anti-LKM) 
Ferritin (haemochromatosis) 
Free copper (Wilson's disease)

Question 14

What imaging can be used in liver failure? What can each of these detect?

Answer 14

Doppler US: potency of hepatic vein (Budd-Chiari syndrome), carcinoma + ascites.
CT or MRI: can exclude other pathology.
CT head: cerebral oedema.
EEG: level of encephalopathy.

Question 15

What is the initial management of liver failure?

Answer 15

Resus.
Treat cause if possible
Monitor: vital signs, PT, pH, creatinine, urine output, encephalopathy

Question 16

How would you manage/ prevent complications of liver failure?

Answer 16

Encephalopathy: lactulose reduces NH3
Abx + antifungal prophylaxis
Hypoglycaemia tx
Haemodialysis for AKI
Coagulopathy tx: IV vitamin K, FFP, platelet infusions
Gastric mucosa protection: PPIs
Cerebral oedema: decrease ICP with mannitol

Question 17

What drugs must you avoid when treating liver failure?

Answer 17

Sedatives (Make monitoring difficult)

Drugs metabolised by the liver

Question 18

List 6 complications of liver failure

Answer 18

Infection: SBP + infection of access lines.
Cerebral oedema associated with intracranial HTN + death
Haemorrhage
Oesophageal varices
AKI
Respiratory failure.

Question 19

What is the prognosis in liver failure?

Answer 19

Depends on aetiology + severity