Liver Failure

Question 1

def

Answer 1

severe liver dysfunction leading to

• jaundice
• encephalopathy
• coagulopathy

Question 2

what are the different classifications of liver failure

Answer 2

1 hyperacute liver failure
-jaundice with encephalopathy occuring in <7days
2 acute
-jaundice with encephalopathy occuring within 1-4wks of onset
3 subacute
-jaundice with encephalopathy occuring within 4-12wks of onset
4 acute-on-chronic
-acute deterioration (decompensation) in patients with CLD

Question 3

aetiology

Answer 3

1 viral
-hep A,B,D,E
2 drugs
-paracetamol
3 less common
-autoimmune hep
-budd-chiari syndrome
-haemochromatosis

Question 4

how does liver failure cause jaundice

Answer 4

decreased secretion of conjugated bilirubin

Question 5

how does liver failure cause encephalopathy

Answer 5

increased delivery of gut-derived products into systemic circulation + brain from decreased extraction of nitrogenous products by liver + portal systemic shunting
(ammonia)

Question 6

how does liver failure cause coagulopathy

Answer 6

decreased synthesis of clotting factors

decreased platelets

Question 7

when would you find decreased platelets in liver failure

Answer 7

hypersplenism if chronic portal hypertension

Question 8

history

Answer 8

1 may be asymptomatic
2 fever + nausea
3 possibly jaundice

Question 9

examination

Answer 9

1 jaundice
2 encephalopathy
3 asterixis
4 ascites
5 bruising/bleeding

Question 10

what is fetor hepaticus

Answer 10

smell of ‘pear drops’

liver failure

Question 11

what is kayser-fleischer rings

Answer 11

dark rings around the iris due to copper deposition caused by wilsons disease

Question 12

investigations

Answer 12

1 identify cause
-viral serology
-paracetamol levels
-autoantibodies
2 bloods
-FBC (low Hb if GI bleed, high WCC if infection)
-UEs (hepatorenal failure)
-LFTs (high bilirubin, low albumin)
-coagulation (high PT)
3 imaging
4 ascitic fluid
5 doppler scan

Question 13

what is the most sensitive marker of liver function

Answer 13

PT time

Question 14

why would ascitic fluid be tapped

Answer 14

to exclude SBP (spontaneous bacterial peritonitis)

>250neutrophil/mm3 indicates SBP

Question 15

why would a doppler scan of hepatic + portal veins be taken

Answer 15

to exclude budd-chiari syndrome

Question 16

management

Answer 16

1 resuscitation
2 treat cause
3 treat complications
4 surgery

Question 17

how would you treat a paracetamol overdose

Answer 17

N-acetylcysteine

Question 18

how would you treat complications in liver failure

Answer 18

1 invasive ventilation + CVS support
2 monitoring
3 manage encephalopathy
-lactulose + phosphate enemas
4 antibiotics + antifungal prophylaxis
5 manage coagulopathy
-IV vitamin K
-FFP
-platelet infusions
6 gastric mucosa protection
-PPIs

Question 19

what should be avoided in treatment of liver failure

Answer 19

sedatives or drugs metabolised by the liver

Question 20

how would cerebral oedema in a patient with liver failure be managed

Answer 20

decrease temp to 30degrees
decreased intracranial pressure with mannitol
hyperventilate

Question 21

what are the kings college hospital criteria for liver transplantation

Answer 21

1 due to paracetamol overdose
-arterial pH <7.3
OR
-PT >100s, creatinine >300 + severe encephalopathy
2 other causes (3/5 required)
-age <10yrs or >40yrs
-bilirubin >300
-by nonA, nonE viral hepatitis or drugs
-interval between jaundice + encephalopathy is >7days
-PT> 100s

Question 22

complications

Answer 22

1 infection
2 coagulopathy
3 hypoglycaemia
4 electrolyte/pH disturbances
5 hepatorenal failure
6 cerebral oedema + increased intracranial pressure

Question 23

prognosis

Answer 23

dependent on cause + severity

those requiring surgery often have poor prognosis