Liver Failure Flashcards
Define Liver Failure
Severe liver dysfunction characterise by jaundice, hepatic encephalopathy and coagulopathy
What are the classifications of Liver Failure (by onset)
Hyperacute: jaundice + encephalopathy <7 days
Acute: jaundice + encephalopathy 1-4 weeks of onset
Subacute: jaundice + encephalopathy within 4-12 weeks
Acute-on-chronic: Acute deterioration (decompensation) in patients with CLD
Aetiology of Liver Failure
Paracetamol overdose (most common in UK/US)
Viral hepatitis (esp. B)
Drug reactions e.g. anti-TB, anti-microbial
Autoimmune hepatitis
Budd-Chiari syndrome
Malignancy
Haemochromatosis
Wilson’s
Alpha-1 antitrypsin deficiency
NAFLD
Pregnancy-related e.g. fatty liver of pregnancy/HELLP syndrome
Symptoms of Liver Failure
Triad of encephalopathy, jaundice and coagulopathy
±
Fever
Nausea and vomiting
Jaundice
Abdominal pain
Malaise
Signs of Liver Failure on examination
Jaundice
Encephalopathy (impaired awareness, sleep alterations, shortened attention span, anxiety, personality change, disorientation, hyperreflexia)
Liver asterisks/flap
Fetor hepaticus
Ascites and splenomegaly
RUQ tenderness
CLD signs: palmar erythema, dupuytren’s contracture, gynaecomastia, bruising, spider naevi
Investigations for Liver Failure
LFTs: enzymes are raised (AST/ALT very high in paracetamol od) | bilirubin high | albumin reduced
Clotting: PT prolonged
FBC: WCC raised in infection |anaemia if bleeding
U+Es: check for renal failure
ESR/CRP: may be raised
ABG: often a metabolic acidosis (esp. in paracetamol od) | elevated lactate (esp. in paracetamol od)
Find the cause: Paracetamol level | urine toxicology | viral serology | ANA/SMA/AMA | Caeruloplasmin | Iron studies | Pregnancy test
USS liver: hepatosplenomegaly, hepatic surface modularity
CT abdomen
Doppler scanning hepatic/portal vein: check for Budd-chiari syndrome
Ascitic fluid tap: check for SBP
Electroencephalogram
Management for Liver Failure
- Intensive care + ABCDE
- Assessment for liver transplant (King’s College Hospital Criteria)
- Treat the cause
- Monitoring
- Manage the complications
How are the following causes of liver failure treated:
Paracetamol
Herpes
Pregnancy
Autoimmune
Hepatitis B
Budd-chiari
Wilson’s
Paracetamol: N-Acetycysteine 140mg/kg
Herpes: acyclovir
Pregnancy: Deliver the foetus
Autoimmune: Methylprednisolone
Hepatitis B: Oral nucleoside
Budd-chiari: Antiocagulation (LMWH) ± TIPS
Wilson’s: Plasmapheresis
What is the King’s College criteria for liver transplant
Paracetamol induced:
Arterial pH <7.3 24h after ingestion OR
- Pro-thrombin time >100s
- AND creatinine >300µmol/L
- AND grade III or IV encephalopathy
Non-paracetamol induced:
Prothrombin time >100s OR
Any three of:
- Drug-induced liver failure
- Age under 10 or over 40 years
- 1 week from 1st jaundice to encephalopathy
- Prothrombin time >50s
- Bilirubin ≥300µmol/L.
Complications of liver failure
Hepatic encephalopathy
Coagulopathy
Infection: Bacterial infection occurs in up to 80% of patients, and fungal infection in around 30%.
Renal failure (hepatorenal syndrome)
Metabolic disorders
Cerebral oedema
GI bleeding
Hypoglycaemia
Respiratory failure
Acid-base disturbance
How are the complications of liver failure managed
Encephalopathy
SBP
Coagulopathy
Hypoglycaemia
Cerebral oedema
Fenal failure
Encephalopathy -> lactulose and phosphate enemas
Antibiotic and antifungal prophylaxis
Hypoglycaemia treatment
Treat coagulopathy -> IV vit K, FFP, platelet infusion
Protect gastric mucosa -> PPI or sulfacralfate
Avoid any sedatives or drugs metabolised by the liver
Cerebral oedema: Nurse patient sat 30 degrees, reduce intracranial pressure by IV mannitol
Renal failure -> haemofiltration and nutritional support
Prognosis for liver failure
ALF secondary to paracetamol overdose is associated with favourable prognosis if treated (75% recover without transplantation)
ALF due to idiosyncratic drug-induced liver injury and hep B has much lower rate of spontaneous recovery (21-40%)
Fulminant presentation of Wilson’s disease carries much higher risk of mortality
