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Gastroenterology > Liver failure > Flashcards

Liver failure Flashcards

1
Q

what is normal plasma bilirubin and bilirubin in jaundice?

A

Normal : 17 micromol/L

Bilirubin > 30 mmol/L = yellow sclera and mucous membranes

Bilirubin >34 mmol/L = yellow skin

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2
Q

What is Cholestasis

A

slow bile flow

Cholestasis - normally results in jaundice

Jaundice does not necessarily mean there is cholestasis

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3
Q

Pre-hepatic jaundice causes?

A

Haemolysis = increased production = conjugated bilirubin

Having a massive transfusions : red cells are short lived

Large haematoma resorption

Ineffective erythropoiesis

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4
Q

Intrahepatic causes of jaundice?

A

Gilbert - decreased BR uptake

Crigler-Najjar - Decreased conjugation BR

Dubin-Johnson, Rotor syndrome - decreased secretion BR in canaliculi

Drug side effects, sepsis, TPN

Acute and chronic liver damage

Estrogens, cystic fibrosis

All cause decreased cholestasis

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5
Q

Post - Hepatic causes of jaundice?

A

Gall stones, tumors

Cause extrahepatic outflow decrease

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6
Q

What is Acute liver failure?

A

Fulminant hepatic failure = rapid development under 8 weeks

  • impaired synthetic function e.g. albumin, INR/PT
  • Encephalopathy
  • sub-fulminant = < 6 months
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7
Q

What is chronic liver failure?

A

Over years

Cirrhosis

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8
Q

What toxins are a common cause of acute liver failure in the west?

A

Paracetamol

Amanita Phalloides

bacillus cereus

Acetaminophen

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9
Q

How can inflammation cause acute liver failure in the east?

A

Exacerbations of chronic Hep B - Hong Kong

Hep E - India

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10
Q

What other causes of acute liver failure are there?

A
  • Diseases of pregnancy:
    AFLP, HELLP syndrome, hepatic infarction, HEV, Budd-Chiari
  • Idiosyncratic drug reactions:
    Single Agent: Isoniazid, NSAID’s, valproate
    Drug combinations: Amoxicillin/clavulanic acid, trimethoprim/sulphamethoxazole, rifampicin/isoniazid
  • Vascular Diseases:
    Ischaemic hepatitis, post-OLTx hepatic artery thrombosis, post-arrest, VOD

-Metabolic causes:
Wilson’s disease
Reye’s syndrome

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11
Q

What are the causes of chronic liver failure?

A
  • Inflammation:
    chronic persistent viral hepatitis
  • Alcohol abuse
  • Side effects of drugs:
    folic acid antagonists phenylbutazone
  • Cardiovascular causes:
    ↓venous return - right heart failure
  • Inherited diseases:
    Glycogen storage diseases, Wilson’s disease, Galactosaemia, Haemochromatosis, α1-antitrypsin deficiency
  • Non alcoholic steatohepatitis (NASH)
  • Autoimmune Hepatitis, PBC, PSC
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12
Q

What are the consequences of liver failure?

A

Coagulopathy and bleeding

Ascites

Encephalopathy and cerebral oedema

Hypoglycaemia

Increased susceptibility to infection

Circulatory collapse, renal failure

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13
Q

What is the effect of decreased protein synthesis?

A

↓ albumin → ascites

Plasma vol ↓
→ secondary hyperaldosteronism
→ hypokalaemia (↓K+)
→ alkalosis

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14
Q

What is the effect of decreased plasma clotting factors?

A

Hepatocytes synthesis all coagulation proteins except von Willebrand factor & factor VIIIC

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15
Q

What does Cholestasis cause?

A

Liver damage

Worsens any bleeding tendency

Decreases bile salts which causes decreased micelles and absorption of Vit K and decreases gamma carboxylation of vit K dependent clotting factors II, VII, IX, X

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16
Q

What are the mechanisms of cholestasis?

A

Canalicular dilation

Decreased cell membrane fluidity

Deformed brush border

Biliary transporters

Increase tight junction permeability

Decrease mitochondrial ATP synthesis

17
Q

What are the consequences of Cholestasis?

A

Increased Bilirubin causing jaundice

  • Pruritus ( itching )
  • Cholesterol deposition
  • Cholangitis
18
Q

What is portal hypertension and what does it cause?

A
  • Decreased lymphatic flow which makes ascites worse

Can also cause splenomegaly which caused thrombocytopenia

Oesophageal varices

19
Q

Why is severe bleeding seen in Liver failure?

A

↓ active clotting factors, thrombocytopenia, & varices

20
Q

What is exudative enteropathy seen in liver failure?

A

↑ ascites → loss of albumin from plasma
favours bacteria in large bowel being “fed” with proteins
↑ liberation of ammonium (toxic to brain)

21
Q

What can cause pre-hepatic portal hypertension?

A

Portal vein thrombosis

22
Q

What can cause post-hepatic portal hypertension?

A

Right heart failure, constrictive pericarditis

23
Q

What can cause intrahepatic portal hypertension?

A
  • Presinusoidal -chronic hepatitis, PBC, granulomas (schistosomiasis, TB, etc.)
  • Sinusoidal - acute hepatitis, alcohol, fatty liver, toxins, amyloidosis, etc.
  • Postsinusoidal - venous occlusive disease of venules & small veins; Budd– Chiari syndrome (obstruction of large HVs).
24
Q

What are the consequences of portal hypertension?

A

Increased portal vein pressure:

  • malabsorption
  • Splenomegaly ( anaemia + thrombocytopaenia )
  • Vasodilators ( glucagon, VIP, substance Pm prostacyclins, NO )

= Decreased blood pressure, increases CO, hyperperfusion of abdomen organs and varices

  • Encephalopathy ( toxins from intestine e.g. NH3, biogenic amines, FFAs, end up in CNS
  • Varices( Thin walled collateral vessels + thrombocytopenia = decreased Clotting factors leading to bleeding )
25
Q

Give examples of Encephalopathies?

A

Apathy, memory gaps, tremor, liver coma

26
Q

Give examples of how liver failure can cause encepthalopathy?

A
  • Hyperammonaemia ↑s :
    GI bleeding ↑s colonic proteins
    liver can’t convert (NH3 NH4+) to urea
  • Hypokalaemia
    → intracellular acidosis → activates ammonium formation in proximal tubules → systemic alkalosis.
  • Toxins (amines, phenols & FFAs) bypass liver → not extracted → encephalopathy.
  • “false transmitters” (e.g., serotonin) from aromatic amino acids in brain → ↑ed in liver failure
    transmitters → encephalopathy.
27
Q

What vessels can become varices?

A

Portal-systemic anastomoses

28
Q

What is the child-pugh score?

A

Assesses disease severity for end-stage liver disease, and a prognosticator for peri-op death

  • Class A: 5-6 points: Expectancy of 15-20 years, 10% peri-operative mortality
  • Class B: 7-9 points: Transplant candidates, may have 30% P-O M
  • Class C: 10-15 points: Life expectancy 1-3 months, 82% P-O M
29
Q

Child pugh score parameters and scores?

A

Total bilirubin : <34 = 1 point
34-51 = 2 points
>51 = 3 points

Serum albumin :
>35 = 1 point
28-35 = 2 points
<28 = 3 points

INR :
<1.7 = 1 point
1.71-2.3 = 2 points
>2.3 = 3 points

Ascites:
None = 1 point
Slight and suppressed with meds = 2 points
moderate despite diuretics = 3 points

Hepatic Encephalopathy :
None = 1 point
Grade I-II = 2 points
grade III-IV = 3 points

30
Q

How to treat encephalopathy?

A

Reduce protein intake

Phosphate enemas/lactulose

No sedation

31
Q

How to treat:

Hypoglycaemia?

Hypocalcaemia?

Renal failure?

Respiratory failure?

Hypotension?

Infection?

Bleeding?

A
  • Hypoglycaemia
    infusion 10-50% dextrose
  • Hypocalcaemia
    10 ml 10% calcium gluconate
  • Renal failure
    haemofiltration
  • Respiratory failure
    ventilation
  • Hypotension
    albumin
    vasoconstrictors
  • Infection
    frequent cultures
    A/Bs
  • Bleeding
    Vit K
    FFP
    platelets
32
Q

What usually causes death in liver failure patients?

A

Bacterial and fungal infections

Circulatory instability

Cerebral Oedema

Renal failure

Respiratory failure

Acid-base and electrolyte disturbance

Coagulopathy

33
Q

What is artificial MARS, Bio- Logic DT?

A

Albumin exchange system

based on selective removal of albumin-bound toxins from blood

  • can also use bioartifical hepatocytes made in culture

or hepatocyte transplantation

34
Q

What can require a liver transplant?

A 
Cirrhosis
Cancer
Cholestatic disease
Acute liver failure
Metabolic disease
Budd- Chairi 
Benign liver tumor
polycystic liver disease

Gastroenterology (10 decks)

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