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liver failure Flashcards

1
Q

What is jaundice?

A

Elevated levels of bilirubin in blood plasma

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2
Q

What blood concentration of bilirubin is: Normal

A

17μmol/L

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3
Q

What blood concentration of bilirubin is: Yellow sclera

A

> 30μmol/L

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4
Q

What blood concentration of bilirubin is: Yellow skin

A

> 34μmol/L

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5
Q

What is cholestasis and its relevance in jaundice?

A

Slow or cessation of bile flow. Is a cause of jaundice

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6
Q

What are some Pre-hepatic causes of jaundice?

A

Haemolytic anaemia, toxins, ineffective erythropoesis, large haematoma resorption

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7
Q

What is a pre-hepatic jaundice typically associated with?

A

Increased production of bilirubin

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8
Q

What are some intrahepatic causes of jaundice?

A

Gilberts syndrome (reduced BR uptake), Crigler-Najar syndrome (reduced BR conjugation), Dubin-Johnson and Rotor syndrome (reduced BR secretion), Sepsis, TPN, drugs, acute & chronic liver failure

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9
Q

What are some post-hepatic causes of jaundice?

A

Gallstones, tumours, obstructions and inflammation of ducts

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10
Q

What is the simple pathophysiology of liver failure?

A

Rate of hepatocyte generation < rate of hepatocyte death (combination of apoptosis and necrosis)

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11
Q

What are the classifications of acute liver failure?

A

Fulminant and Sub-Fulminant

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12
Q

What is Fulminant liver failure?

A

rapid onset of liver failure (<8wks), reduced synthetic function and encephalopathy with previously normal liver function

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13
Q

Sub-fulminant liver failure?

A

< 6 month onset

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14
Q

What is chronic liver failure?

A

Onset over years, marked cirrhosis

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15
Q

What is the most common toxin to cause acute LF in the western world?

A

Paracetamol overdose (behind amanita phalloides, bacillus cereus)

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16
Q

What is the most common cause of acute liver failure in the eastern world?

A

Inflammation (due to Hep B or E)

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17
Q

What process exclusive to females can induce acute liver failure?

A

Acute fatty liver of pregnancy (AFLP), HELLP syndrome (haemolysis, elevated liver enzy. Low platelets), hepatic infarction, Budd-Chiari syndrome and Hep E

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18
Q

Which common drug interactions can cause acute liver failure?

A

Amoxicillin+clavulanic acid, trimethoprim+sulphamethoxazole, rifampicin+isoniaizid

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19
Q

What single drugs can cause acute liver failure?

A

Isoniazid, NSAID’s, valproate

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20
Q

Name two metabolic diseases which can cause acute liver failure?

A

Wilsons disease, Reye’s syndrome

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21
Q

Name some vascular diseases which can cause acute liver failure?

A

Ischaemic hepatitis, post-OLTx, hepatic artery thrombosis, post arrest, VOD

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22
Q

Name all the broad causes of chronic liver failure (I ‘AD CINA - say it in a cockney accent)

A

Inflammation, Alcohol abuse, Drug side effects, Cardiovascular effects, Inherited disease, NASH, Autoimmunity

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23
Q

Explain the process of cirrhosis

A

Noxious factor -> necrosis -> enzyme leakage -> cytokines activate kupffner and granulocytes -> fibroblast proliferation and microfibroblast activation -> fibrosis -> cirrhosis -> inflammation -> fibrosis etc

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24
Q

Consequence of LF on: Production of clotting factors

A

coagulopathy and bleeding

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25
Q

Consequence of LF on: Protein synthesis

A

ascites

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26
Q

Consequence of LF on: Detoxification

A

encephalopathy and cerebral oedema

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27
Q

Consequence of LF on:Glycogen storage

A

hypoglycaemia

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28
Q

Consequence of LF on: Immunological function, globin production

A

susceptibility to infection

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29
Q

Consequence of LF on: Homeostasis

A

circulatory collapse, renal failure, MOF

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30
Q

Reduction in what protein leads to ascites?

31
Q

What does reduced albumin result in?

A

2° hyperaldosteronism, hypokalaemia and alkalosis

32
Q

What clotting factors are produced in the liver?

A

All but Von Willebrand and VIII

33
Q

What is the difference between chronic and acute liver failure?

A

Onset of failure and causes, cirrhosis

34
Q

How does cholestasis aggravate bleeding tendencies?

A

Reduced bile salts, reduced micelles and absorption of Vit K resulting in poor γ-carboxylation of vit K dependent clotting factors (prothrombin, VII, IX, X)

35
Q

What is one of the biggest signs of liver failure?

A

Pruritus - scratch marks, pain in upper right quadrant, abdominal swelling, cholesterol deposits around eyes, nausea, sleepiness and confusion. Gynaecomastia in males. Spider naevi (more than 5)

36
Q

What are spider naevi?

A

Cluster of visible vessels under the skin with a central spot - if pressed they refill from the centre

37
Q

What is clubbing?

A

Curved flat nails

38
Q

How is gynaecomastia caused by liver failure?

A

Increased oestrogen production and reduced clearance results in a rise in oestrogen levels above testosterone

39
Q

How is excessive bleeding possible?

A

Thrombocytopenia, reduced clotting factors and varices (thin walled collateral vessels taking more blood than normal)

40
Q

How is cholestasis caused by liver failure?

A 
Canalicular dilation
cell membrane stiffness
deformed brush border
biliary transporter issues
increased tight junction permeability
decreased mitochondrial ATP synthesis
41
Q

What are the consequences of cholestasis on the body?

A

Jaundice. Pruritis. Cholesterol deposition (esp around eyes) malabsorption and steatorrhoea, cholangitis

42
Q

How can portal hypertension be caused by liver failure?

A

Scar tissue causes reduced hepatic venous outflow causing pressure buildup

43
Q

What is exudative/hepatic encephalopathy?

A

Exudation of fluid over BBB which is carrying toxins causes encephalopathy

44
Q

What are the signs of encephalopathy?

A

Memory loss, confusion, tiredness, loss of consciousness

45
Q

How is exudative/hepatic encephalopathy caused?

A

Loss of albumin causes ascites, which causes bacteria in large bowel to increase liberation of ammonia (very toxic to brain)
and/or toxins bypass liver (non-functional) so aren’t extracted
and/or false transmitters from aromatic AAs increase

46
Q

What are the prehepatic causes of portal hypertension?

A

Portal vein thrombosis

47
Q

What are the intrahepatic causes of portal hypertension?

A

can be presinusoidal, sinusoidal and post sinusoidal

48
Q

Presinusoidal causes of PH

A

chronic hepatitis, PBC, granulomas (TB etc)

49
Q

Sinusoidal causes of PH

A

acute hepatitis, ALCOHOL, FATTY LIVER, amyloidosis, toxins

50
Q

post sinusoidal causes of PH

A

venous occlusive disease, Budd-Chiari

51
Q

What are the posthepatic causes of PH?

A

Right heart failure, constrictive pericarditis

52
Q

What are the consequences of PH on the body?

A

Malabsorption, splenomegaly, thrombocytopenia and anaemia, vasodilation (hypotension), encephalopathy, varices

53
Q

Describe a few causes of hepatic encephalopathy

A

Hyperammonaemia, hypokalaemia, toxins, false transmitters

54
Q

Where are the most common varices found? What veins are involved?

A

Oesophagus, azygos vein and oesophageal tributaries of left gastric vein

55
Q

How is the severity of liver failure scored?

A

Child-Pugh scoring using blood tests and examinations

56
Q

What is the life expectancy of someone with a Child-Pugh score of 5-6

A

15-20 years

57
Q

What is the treatment for someone with a Child-Pugh score of 7-9

A

Transplant candidates! (but 30% perioperative mortality)

58
Q

What is the life expectancy of someone with a Child-Pugh score of 10-15

A

1-3 months :( not recommended transplant as 82% risk of POM

59
Q

What sort of treatment is given to those with liver failure?

A

Supportive treatments unless transplant is possible

60
Q

What is the most common cause of death during liver failure?

A

Bacterial or fungal infections

61
Q

How do you support encephalopathy?

A

Reduce protein intake, phosphate enemas, lactulose (empty the bowels), avoid any sedation

62
Q

How do you support hypoglycaemia and hypocalcaemia?

A

Infuse 10-50% dextrose, 10ml 10% calcium gluconate

63
Q

How do you support renal and respiratory failure?

A

Haemofiltration, ventilation

64
Q

What would you give to help hypotension?

A

Albumin and vasoconstrictors

65
Q

What would you give to prevent infection after liver failure?

A

Frequent cultures and antibiotics

66
Q

What would you give to prevent bleeds after liver failure?

A

Vitamin K, Fresh Frozen Plasma, platelets

67
Q

For what is liver transplant most commonly done?

A

Chronic liver failure (cirrhotic liver)

68
Q

What type of cancer would you likely treat with a liver transplant?

A

Hepatocellular cancer

69
Q

What type of cancer would you not want to use a liver transplant for?

A

Any metastatic cancers - immunosuppression after transplant is a BAD IDEA

70
Q

How does portal hypertension increase varices?

A

increased vasodilation release to relieve PH (vip, prostacyclins, glucagon) decreases blood pressure.
cardiac output increases to stabilise o2, leading to HYPERperfusion of abdo - varices increase

71
Q

what are varices?

A

thin walled collateral vessels take on too much load and enlarge due to PH or obstruction, combined w thrombocytopenia and decreased clotting factors, increases bleeds of veins

72
Q

what is icterus?

A

fancy word for jaundice

73
Q

how does secondary hyperaldosteronism cause encephalopathy?

A

produces hypokalaemia, leads to intracellular acidosis, ammonia formation in proximal tubules of kidney leading to systemic alkalosis which causes the encephalopathy

74
Q

how does liver failure induce secondary hyperaldosteronism?

A

as PH induces vasodilation, BP decreases which is countered by increased renin-angiotensin-aldosterone system, increasing aldosterone with little negative feedback as the BP doesn’t then increase

pancreas and liver (3 decks)

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