Liver failure Flashcards

1
Q

define liver failure?

A

severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy

can occur suddenly in a previously healthy liver ( acute liver failure) but more often occurs as a result of decompensation of chronic liver disease ( acute- on-chronic hepatic failure)

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2
Q

what is the typical presentation of liver failure?

A

cirrhosis + acutely ill/jaundice

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3
Q

how is liver failure classified? and what are the classifications?

A

based on the time interval between onset of jaundice and development of hepatic encephalopathy

Hyperacute = < 7 days

Acute = 1-4 weeks

Subacute = 4-12 weeks

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4
Q

what is acute- on-chronic liver failure?

A

acute deterioration ( decompensation) in patients with chronic liver disease

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5
Q

summarise the epidmemiology of liver failure?

A

paracetamol overdose counts for 50% of acute liver failure in the UK

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6
Q

what are the main causes of liver failure?

A

viral

  • hepatitis A , B,C, D and E

Drugs

  • paracetamol overdose
  • idiosynchronatic drug reactions eg anti-TB therapy
  • St Johns wort
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7
Q

what are the less common causes of liver failure?

A

autoimmune hepatitis

Budd-chiari syndrome ( occlusion of hepatic veins)
pregnancy- related

malignancy ( Lymphoma)

haemochromatosis ( iron levels in the body build up over many years)

mushroom poisoning ( amanita phalloides)

Wilson’s disease

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8
Q

explain the pathogenesis of the manifestations of liver failure?

A

jaundice- due to decreased secretion of conjugated bilirubin

encephalopathy

  • nitrogenous products ( ammonia) is absorbed in the gut via the portal circulation to the liver
  • a normal liver would be able to extract these harmful substances
  • However, if the liver is failiing-> toxic products can go through the liver and reach the brain and have its effects

Coagulopathy

  • reduced synthesis of clotting factors
  • reduced platelets
  • platelet functional abnormalities associated with jaundice or renal failure
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9
Q

what are the presenting symptoms of liver failure?

A

may be asymptomatic

fever

nausea

jaundice ( not always)

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10
Q

what are the signs of liver failure on physical examination ?

A

jaundice

encephalopathy

asterixis

clubbing

Fetor hepaticus (smell of pear drops)

Ascites and splenomegaly (less common if acute or hyperacute)

  • Ascites as low albumin therefore lower oncotic press and so more fluid leak

Bruising or bleeding

Signs of secondary causes (e.g. bronze skin colour, Kayser-Fleisher rings)

Pyrexia - may indicate infection or liver necrosis

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11
Q

what investigations should you do to find the cause of liver failure?

A

viral serology

paracetamol levels

autoantibodies ( ASM, Anti-LKM)
ferritin ( haemochromatosis)

caeruloplasmin and urinary copper ( Wilson’s disease)

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12
Q

what are the appopriate investigations for liver failure?

A

investigations for cause

bloods

Dopper scan of hepatic or portal veins- check for Budd-chiari sydrome

MRI of liver is much better than CT

ECG- monitor encephalopathy

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13
Q

Describe the bloods for liver failure?

A

FBC

  • Low Hb (if GI bleed)
  • High WCC (if infection)

U&Es

  • May show renal failure (hepatorenal syndrome)

Glucose

LFTs

  • High bilirubin
  • High AST, ALT, ALP, GGT
  • Low albumin

ESR/CRP

Coagulation screen

  • Prolonged PT
  • Prolonged APTT
  • Prolonged bleeding time
  • Reduced plts

ABG - to determine blood pH

Group and save

  • Liver US/CT
  • Ascitic Tap

Send for MC&S

  • If neutrophils > 250/mm3 = spontaneous bacterial peritonitis
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14
Q

outline a management plan for liver failure?

A

Resuscitation - ABC

Treat the cause if possible:

  • N-acetylcysteine - treatment for paracetamol overdose

Treatment/prevention of complications (invasive ventilation and cardiovascular support is often required)

  • Monitor - vital signs, PT, pH, creatinine, urine output, encephalopathy
  • Manage encephalopathy: lactulose and phosphate enemas
  • Antibiotic and antifungal prophylaxis
  • Hypoglycaemia treatment
  • Coagulopathy treatment - IV vitamin K, FFP, platelet infusions
  • Gastric mucosa protection - PPIs or sucralfate
  • AVOID sedatives or drugs metabolised by the liver
  • Cerebral oedema - decrease ICP with mannitol

Renal Failure

  • Haemodialysis
  • Nutritional support

Surgical - liver transplant

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15
Q

what are the possible complications of liver failure?

A

Infection

Coagulopathy

Hypoglycaemia

Disturbance of electrolyte balance and acid-base balance

Disturbance of cardiovascular system

Hepatorenal syndrome

Cerebral oedema (causing raised ICP) – as liver fails, nitrogenous waste builds up and passes to the brain where astrocytes clear it by processes involving conversion of glutamate to glutamine. This excess glutamine causes an osmotic imbalance and a shift of fluid into the cells – cerebral oedema

Respiratory failure

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16
Q

summarise the prognosis for patients with liver failure?

A

depends on severity and aetiology