Liver failure

Question 1

Define

Answer 1

Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy

• Hyperacute liver failure: Jaundice with encephalopathy occurring in less than 7 days
• Acute: Jaundice with encephalopathy occurring from 1 to 4 weeks of onset
• Subacute: Jaundice with encephalopathy occurring within 4-12 weeks of onset
• Acute-on-chronic: Acute deterioration (decompensation) in patients with chronic liver disease

Question 2

Aetiology/risk factors

Answer 2

• Viral: Hepatitis A, B, D, E, ‘non-A-E hepatitis’
• Drugs: Paracetamol overdose, idiosyncratic drug reactions
• Less common: Autoimmune hepatitis, Budd-Chiari syndrome, pregnancy-related, malignancy (e.g. lymphoma), hemochromatosis, mushroom poisoning, Wilson’s disease

Question 3

epidemeology

Answer 3

• Jaundice: Reduced secretion of conjugated bilirubin
• Encephalopathy: Increased delivery of gut-derived products into the systemic circulation and brain from reduced extraction of nitrogenous products by liver and portal systemic shunting. Ammonia may play a part
• Coagulopathy: Reduced synthesis of clotting factors, reduced platelets (hypersplenism if chronic portal hypertension) or platelet functional abnormalities associated with jaundice or renal failure

Question 4

Symptoms

Answer 4

• May be asymptomatic

- Fever, nausea and possibly jaundice

Question 5

signs

Answer 5

Jaundice, encephalopathy, liver asterixis, fetor hepaticus

• Ascites and splenomegaly
• Bruising or bleeding from puncture sites or GI tracts
• Look for secondary causes (e.g. bronze skin colour, Kayser-Fleischer rings)
• Pyrexia may reflect infection or liver necrosis

Question 6

Investigations

Answer 6

• Identify the cause: Viral serology, paracetamol levels, autoantibodies (e.g. ASM, LKM antibody, immunoglobulins) ferritin, caeruloplasmin and urinary copper
• Blood (in addition to above): FBC: Reduced Hb in GI bleed, Raised WCC if infection. U&E: renal failure. Glucose, LFT, group and save
• Ultrasound liver, CT scan: image liver
• Ascitic fluid: Tap ascites and send for microscopy, culture, biochemistry
• Doppler screening of hepatic or portal veins: To exclude Budd-Chiari syndrome
• Electroencephalogram: To monitor encephalopathy

Question 7

management

Answer 7

• Resuscitation: (According to airway, breathing, circulation): ITU care and specialist unit support essential

Treat the cause if possible: N-acetylcysteine for paracetamol overdose

 Treatment/prevention of complications: 
Monitor, Manage encephalopathy, 
Antibiotic and antifungal prophylaxis, 
Hypoglycaemia treatment,
 Coagulopathy treatment, 
Gastric mucosa protection,
 Avoid sedatives or drugs metabolised by liver

ONLY CURATIVE IS LIVER TRANSPLANT

Question 8

complications

Answer 8

• Infection
• Coagulopathy
• Hypoglycaemia
• Disturbances of electrolyte acid-base and cardiovascular system, hepatorenal syndrome, cerebral oedema, raised intracranial pressure, respiratory failure

Question 9

prognosis

Answer 9

Depends on severity and aetiology of liver failure

Traditional prognostic score for surgical mortality is the Child-Pugh score( made up of total bilirubin, PT, hepatic encephalopathy and ascites)