Liver Failure Flashcards
Functions of the liver.
Glycogen storage, production and release of glucose, absorbs fats, fat soluble vitamins and iron.
Production of cholesterol
Dissolves dietary fats
Bilirubin
Production of clotting factors
Detoxification - drug excretion and alcohol breakdown
Immune function via Kupffer cells
Production of albumin and other binding proteins
Important history in liver disease.
Blood transfusions prior to 1990 in the UK?
IV drug user?
Operations and vaccination with dubious sterile procedures?
Sexual history
Medications (ALL OF THEM)
FH of liver disease, diabetes or IBD
Obesity and other features of metabolic syndrome
Alcohol?
Foregin travel?
Tattoos?
Definition of liver failure.
May be recognised by the developoment of coagulopathy ( INR > 1.5) and encephalopathy.
Definition of acute liver failure.
Hyperacute = 7 days or less onset
Acute = 8-21 days onset
Subacute = 4 to 26 weeks onset
Definition of chronic liver failure.
Starts with acute liver failure/disease on going effects beyond 6 months
Common causes of acute liver failure..
Resolves in 6 months due to
Hep A, E, CMV, EBV (viral)
Drug induced liver injury (DILI)
Common causes of chronic liver failure.
May progress to cirrhosis.
Alcohol
Hep C
Non-alcoholic steatohepatitis (NASH)
Autoimmune (PBC, PSC, AIH)
Causes of liver failure.
Infections - Hep B, C, CMV, A, E, yellow fever, leptospirosis
Drugs - Paracetamol overdose, halothane, isoniazid etc…
Budd-Chiari, Veno-occlusive disease
Toxins
Alcoholic fatty liver disease
PBC
PSC
Haemochromatosis
Autoimmune hepatitis
alpha-antitrypsin def.
Wilson’s disease
Malignancy
Signs of liver failure.
Jaundice
Hepatic encephalopathy
Fetor hepaticus
Asterixis
Constructional apraxia
Signs of chronic liver disease suggest acute-on-chronc liver failure
Grades of hepatic encephalopathy
Grade 1 - Psychomotor slowing, constructional apraxia, poor memory and reversed sleep pattern
Grade 2 - Lethargy, disorientation, agitation and irritability, asterixis.
Grade 3 - Drowsy
Grade 4 - Coma
Investigations of liver failure.
Acute vs chronic doesn’t matter. Investigations are alike.
Bloods - FBC, LFTs, Clotting (thrombocytopenia is a sensitive marker for liver fibrosis), glucose, paracetamol levels, Hep serology, CMV and EBV serology, ferritin, ceruloplasmin levels, autoantibodies, alpha-antitrypsin, coeliac serology, TFTs and lipids.
Microbiology - Blood cultures, urine culture, ascitic tap for MC&S of ascites.
Radiology - CXR, abdo USS, Dopples flow studies
Neurophysiology - EEG
If the LFTs suggest a cholestatic abnormality, what should be done?
Ultrasound to assess if the ducts are dilated (obstructive) or not.
USS can also be used to assess cirrhosis
USS findings of cirrhosis.
Coarse texture
Nodularity
Splenomegaly or ascites
Causes of liver failure when ALT >500.
Viral
Ischaemia
Drug-induced (paracetamol very common)
Autoimmune
Causes of liver failure when ALT 100-200.
Non-alcoholic steotohepatitis
Autoimmune hepatitis
Chronic viral hepatitis
Drug induced liver injury