Liver Failure Flashcards
Define Liver Failure?
Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy
What is Liver Failure classifed based on?
The time interval between the onset of jaundice and the development of hepatic encephalopathy
What is the classification of Liver Failure?
Hyperacute = < 7 days Acute = 1-4 weeks Subacute = 4-12 weeks
What is Acute-on-Chronic Liver Failure?
Acute deterioration (decompensation) in patients with chronic liver disease
What are the viral causes of Liver Failure?
Hepatitis A, B, C, D and E
What drugs can cause Liver Failure?
Paracetamol Overdose
Idiosyncratic drug reactions
What are some of the less common causes of Liver Failure?
Autoimmune hepatitis Budd-Chiari syndrome Pregnancy-related Malignancy (e.g. lymphoma) Haemochromatosis Mushroom poisoning (Amanita phalloides) Wilson's Disease
What is the pathogenesis of Jaundice in Liver Failure?
Due to decreased secretion of conjugated bilirubin
What is the pathogenesis of Encephalopathy in Liver Failure?
Nitrogenous products (e.g. ammonia) is absorbed in the gut and goes via the portal circulation to the liver
A normal liver would be able to extract these harmful substances
However, if the liver is failing, these toxic products can go through the liver and reach the brain and exert its effects
What is the pathogenesis of Coagulopathy in Liver Failure?
Reduced synthesis of clotting factors
Reduced platelets
Platelet functional abnormalities associated with jaundice or renal failure
What is the epidemiology of Liver Failure?
Paracetamol overdose counts for 50% of acute liver failure in the UK
What are the presenting symptoms of Liver Failure?
May be asymptomatic
Fever
Nausea
Jaundice (not always)
What are the signs of Liver Failure on physical examination?
Jaundice Encephalopathy Asterixis Fetor Hepaticus Ascites and Splenomegaly (less common if acute or hyperacute) Bruising or bleeding Signs of secondary causes Pyrexia
What are some of the signs of secondary causes in Liver Failure?
e.g.
bronze skin colour
Kayser-Fleisher rings
What can Pyrexia indicate if it’s a sign for Liver Failure?
Infection or Liver necrosis
What investigations do we do for Liver Failure?
Investigations to Identify the Cause Bloods Liver US/CT Ascitic Tap Doppler scan of hepatic or portal veins EEG
What investigations do we do to identify the cause of Liver Failure?
Viral serology Paracetamol levels Autoantibodies (e.g. ASM, Anti-LKM) Ferritin (haemochromatosis) Caeruloplasmin and urinary copper (Wilson's Disease)
What bloods do we do for Liver Failure?
FBC U&Es Glucose LFTs ESR/CRP Coagulation screen ABG Group and save
What do we look for on an FBC for Liver Failure?
Low Hb (if GI bleed) High WCC (if infection)
Why do we do U&Es for Liver Failure?
May show renal failure (hepatorenal syndrome)
What are we looking for on LFTs for Liver Failure?
High bilirubin
High AST, ALT, ALP, GGT
Low albumin
Why do we do an ABG for Liver Failure?
To determine blood pH
Why do we do an Ascitic Tap for Liver Failure?
Send for MC&S
If neutrophils > 250/mm^3 = spontaneous bacterial peritonitis
Why do we do a Doppler scan of hepatic or portal veins for Liver Failure?
Check for Budd-Chiari Syndrome
Why do we do an EEG for Liver Failure?
Monitor Encephalopathy
What is the general management plan for Liver Failure?
Resuscitation - ABC Treat the cause Treatment/prevention of complications (invasive ventilation and cardiovascular support is often required) Treatment of Renal Failure Surgical
What is the treatment for Paracetamol Overdose?
N-acetylcysteine
What is some of the steps taken to treat and prevent complications of Liver Failure?
Monitoring Manage encephalopathy Antibiotic and antifungal prophylaxis Hypoglycaemia treatment Coagulopathy treatment Gastric mucosa protection Avoid sedatives or drugs metabolised by the liver Cerebral Oedema
What do we monitor in the prevention of compliations of Liver Failure?
Vital Signs PT pH Creatinine Urine output Encephalopathy
How do we manage encephalopathy as a complication of Liver Failure?
Lactulose and phosphate enemas
How do we treat Coagulopathy as a complication of Liver Failure?
IV Vitamin K
FFP
Platelet infusions
How do we protect Gastric Mucosa in Liver Failure?
PPIs
Sucralfate
How do we manage/prevent cerebral oedemas in Liver Failure?
Decrease ICP with mannitol
How do we manage Renal Failure as a complication of Liver Failure?
Haemodialysis
Nutritional Support
What is the surgical management plan for Liver Failure?
Liver transplant
What are the possible complications of Liver Failure?
Infection Coagulopathy Hypoglycaemia Disturbance of electrolyte balance and acid-base balane Disturbance ofCVS Hepatorenal syndrome Cerebral Oedema (causing raised ICP) Respiratory Failure
What is the prognosis for patients with Liver Failure?
Depends on severity and aetiology
What is Pyrexia?
Raised body temperature (fever)
What is Fetor Hepaticus?
Your breath has a strong, musty smell
