Liver Failure

Question 1

Define Liver Failure

Answer 1

Severe liver dysfunction characterise by jaundice, hepatic encephalopathy and coagulopathy

Question 2

What are the classifications of Liver Failure (by onset)

Answer 2

Hyperacute: jaundice + encephalopathy <7 days

Acute: jaundice + encephalopathy 1-4 weeks of onset

Subacute: jaundice + encephalopathy within 4-12 weeks

Acute-on-chronic: Acute deterioration (decompensation) in patients with CLD

Question 3

Aetiology of Liver Failure

Answer 3

Paracetamol overdose (most common in UK/US)
Viral hepatitis (esp. B)
Drug reactions e.g. anti-TB, anti-microbial 
Autoimmune hepatitis
Budd-Chiari syndrome 
pregnancy-related
Malignancy 
Haemochromatosis
Wilson's

Question 4

Symptoms of Liver Failure

Answer 4

Asymptomatic

Fever
Nausea and vomiting
Jaundice
Abdominal pain
Malaise

Question 5

Signs of Liver Failure on examination

Answer 5

Jaundice
Encephalopathy (impaired awareness, sleep alterations, shortened attention span, anxiety, personality change, disorientation, hyperreflexia)
Liver asterisks/flap 
Fetor hepaticus 
Ascites and splenomegaly 
RUQ tenderness 

CLD signs: palmar erythema, dupuytren’s contracture, gynaecomastia, bruising, spider naevi

Question 6

Investigations for Liver Failure

Answer 6

LFTs: enzymes are raised (AST/ALT very high in paracetamol od) | bilirubin high | albumin reduced
Clotting: PT prolonged
FBC: WCC raised in infection |anaemia if bleeding
U+Es: check for renal failure
ESR/CRP: may be raised
ABG: often a metabolic acidosis (esp. in paracetamol od) | elevated lactate (esp. in paracetamol od)

Find the cause: Paracetamol level | urine toxicology | viral serology | ANA/SMA/AMA | Caeruloplasmin | Iron studies | Pregnancy test

USS liver: hepatosplenomegaly, hepatic surface modularity
CT abdomen
Doppler scanning hepatic/portal vein: check for Budd-chiari syndrome

Ascitic fluid tap: check for SBP
Electroencephalogram

Question 7

Management for Liver Failure

Answer 7

1. Intensive care + ABCDE
2. Assessment for liver transplant (King’s College Hospital Criteria)
3. Treat the cause
4. Monitoring
5. Manage the complications

Question 8

How are the following causes of liver failure treated:
Paracetamol 
Herpes 
Pregnancy 
Autoimmune
Hepatitis B 
Budd-chiari 
Wilson's

Answer 8

Paracetamol: N-Acetycysteine 140mg/kg

Herpes: acyclovir

Pregnancy: Deliver the foetus

Autoimmune: Methylprednisolone

Hepatitis B: Oral nucleoside

Budd-chiari: Antiocagulation (LMWH) ± TIPS

Wilson’s: Plasmapheresis

Question 9

Complications of Liver Failure

Answer 9

Hepatic encephalopathy 
Coagulopathy 
Infection
Renal failure (hepatorenal syndrome)
Metabolic disorders
Cerebral oedema 
GI bleeding
Hypoglycaemia
Respiratory failure

Question 10

Prognosis for Liver Failure

Answer 10

Secondary to paracetamol overdose - favourable prognosis if treated (75% without transplant)
Drug-induced and hep B have a lower rate of spontaneous recovery
Wilson’s disease - high risk of mortality