Liver Failure Flashcards
What is liver failure?
Development of coagulopathy (INR > 1.5) and encephalopathy
What are causes of liver failure?
Infections:
- viral hapatitis - Hep B, C, CMV
- yellow fever
Drugs:
- paracetamol overdose
- isoniazid
Toxins
- Amanita phalloides mushroom
Vascular
- Budd-Chiari dynsrome
Alcohol
Fatty liver disease
Autoimmune:
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
Metabolic disease: Haemochromatosis Alpha-1-antitrypsin deficiency Wilson's disease Fatty liver of pregnancy
Malignancy
What are signs of acute liver failure?
Jaundice - unconjugated
Hepatic encephalopathy
Fetor hepaticus - pear drops smell
Hepatic flap
What causes hepatic encephalopathy? Features of each grade? Ddx
Nitrogenous waste (ammonia) builds up int he circulation and passes to the brain. Astrocytes clear it leading to glutamine production causing an osmotic imbalance and a shift of fluid into the cells --> cerebral oedem
1 Altered mood/behaviour, sleep disturbance, dyspraxia
- Increasing drowsiness, confusion, slurred speech ± liver flap
- Incoherent, restless, liver flap, stupor
- Coma
Hypoglycaemia
Sepsis
Trauma
Postictal
What investigations in acute hepatic failure?
Bloods: FBC (infection? anaemia) U&E (electrolyte derangement) LFT Clotting (increased PT) INR Glucose Paracetamol/toxin level Hepatitis CMV and EBV serology - glandular fever deranges LFTs Alpha-1-antitrypsin autoantibodies
Microbiology:
Blood culture
Urine culture
Ascitic tap for MC&S
Imaging:
CXR
Abdo US
Doppler flow studeis of portal vein and hepatic vein
What is immediate management of actue liver failure
Nurse in ITU
Protect airway with intubation
NG tube to avoid aspiration and remove blood from stomach
Urinary cathery
IV access
Monitor observations, urine output and daily weights
Check FBC, U&E, LFT and clotting daily
10% glucose IV 1L/12h to avoid hypoglycaemia - glucose every 1-4h
Treat cause if known (GI bleed, sepsis, poisoning)
Dietary help if malnourished - thiamine, folate supplements
Treat seizures with phenytoin
Haemodialysis if renal failure
Avoid drugs with hepatic metabolism
Consider PPI
Transplant
What are complications of acute liver failure?
Cerebral oedema Ascites Bleeding Infection Hypoglycaemia Encephalopathy
How do you treat cerebral oedema?
ITU
20% mannitol IV
Hyperventilate
Dexamethasone
Treatment for ascites
Restrict fluid
Low-salt diet
Daily weights
Diuretics
Treatment for bleeding
Vitamin K 10mg/d IV
Platelets
FFP + blood as needed
Endoscopy
Infection treatment
Ceftriaxone 1-2g IV (not gentamicin)
Treatment fo hypoglycaemia
50ml of 50% glucose IV
Treatment of encephalopathy?
Avoid sedatives 20 degree head up ITU Electrolytes Lactulose Rifamixin - reduces number of nitrogen forming gut bacteria
What are hepatotoxic drugs?
Paracetamol Methotrexate Isoniazid Azathioprine Oestrogen 6-MP SAlicylates Tetracycline
What is hepatorenal syndrome?
Cirrhosis + ascites + renal failure (if other causes of renal failure excluded)
Abnormal systemic vasodilation but renal vasoconstriction
HRS1 - rapidly progressive deterioration - haemodialysis
HRS2 - steady deterioration - transjugular intrahepatic porto-systemic stent shunting (TIPS)
Tranplant may be required
