Liver Failure

Question 1

Liver failure definition

Answer 1

Development of coagulopathy (INR>1.5) and encephalopathy

Question 2

Liver failure classification

Answer 2

Hyperacute <7d onset
Acute 8-21d
Subacute 4-26 weeks
Chronic on a background of cirrhosis
Fulminant from massive necrosis of hepatocytes leading to severe impairment

Question 3

Liver failure causes

Answer 3

Infective - Viral, yellow fever, leptospirosis
Drugs - paracetamol, halothane, isoniazid
Toxins - Amanita phalloides, carbon tetrachloride
Vascular - Budd-Chiari, veno-occlusive disease
Other - Alcohol, NASH, genetic conditions, PBC/PSC, malignancy

Question 4

Liver failure signs

Answer 4

Jaundice
Hepatic encephalopathy
Asterixis
Constructional apraxia
Fetor hepaticus (breath smells like pear drops)

Question 5

Liver failure tests

Answer 5

FBC (infection/bleed), LFTs, Autoantibodies

Any other test for causes

Question 6

Liver failure management

Answer 6

Treat complications (cerebral oedema, enceph, coagulopathy, hypoglycaemia)
Ceftriaxone 1-2g/24h
Avoid constipating drugs (inc enceph risk), hepatotoxic drugs and warfarin enhancing

Question 7

What is hepatorenal syndrome

Answer 7

Cirrhosis + ascites + renal failure = HRS if other causes of renal impairment excluded
Splanchnic and systemic venodilation but renal vasoconstriction

Question 8

HRS types

Answer 8

HRS 1 rapidly progresses, decrease in circulatory + renal function
HRS 2 more steady deterioration, TIPS may be required

Question 9

Indications for transplant in liver failure (paracetamol induced)

Answer 9

KCH criteria
Paracetamol induced: arterial ph<7.3 24h post ingestion
OR all of (PT>100s, creatinine >300­µmol/L, Grade 3/4 enceph)

Question 10

Indications for transplant in liver failure (non-paracetamol induced)

Answer 10

KCH criteria
PT>100s
OR 3 of (drug-induced; 1wk from 1st jaundice to enceph; <10yrs or >40yrs; PT>50s; bilirubin >300µmol/L)