Liver failure & Cirrhosis

Question 1

How can liver failure be defined?

Answer 1

The development of coagulopathy and encephalopathy?

Question 2

How can coagulopathy be defined?

Answer 2

If the INR is >1.5

Question 3

What are the different types of liver failure?

Answer 3

Hyperacute is <7 days

Acute is 8-21 days

Subacute is 4-26 weeks

Question 4

What are the causes of liver failure?

Answer 4

Vascular = vino-occlusive disease and Budd-Chiari syndrome

Infection=Viral hepatitis (B, C, CMV), yellow fever

Trauma

Autoimmune disease

Metabolic = A1AT deficiency, Wilsons disease, haemochromatosis

Iatrogenic = alcohol, drugs (paracetamol, isoniazid)

Neoplasia

Additionally: NAFLD, fatty liver of pregnancy

Question 5

What investigations (other than routine) would you order for a patient with suspected liver disease?

Answer 5

Paracetamol levels

Full serology screen: Hepatitis antigens and antibodies

Clotting

Glucose

A1AT

Caeruloplasmin

Haematinics

Question 6

What investigations for microbiology would you order

Answer 6

Urine MC&S

Blood culture

Ascitic tap for MC&S = neutrophils >250 indicates SBP

Question 7

How would you manage a patient with liver failure?

Answer 7

Urinary catheter and monitor fluid balance

Central venous catheter to monitor fluid balance

Regular obs

Weight daily to monitor fluid offload

Daily bloods

Give 10% dextrose and monitor blood glucose every 1-4 hours

Consider PPI against stress ulceration

Question 8

What is hepatorenal syndrome?

Answer 8

Cirrhosis, ascites and renal failure

Question 9

What are the most common causes of Cirrhosis?

Answer 9

Hepatitis B, C and alcoholism

Question 10

What clinical signs of note might you notice in a patients hands with Cirrhosis?

Answer 10

Clubbing

Leuconychia

Palmar erythema

Dupuytrens contracture

Spider naevi

Question 11

What signs might you note of the reproductive organs in patients with liver cirrhosis?

Answer 11

Gynaecomastia and testicular atrophy

Question 12

What are the common complications of Cirrhosis?

Answer 12

Ascites

Hypoglycaemia

Sepsis

Spontaneous bacterial peritonitis

Hypoalbuminaemia

Coagulopathy and Encephalopathy

Question 13

What are common complications of portal hypertension?

Answer 13

Splenomegaly

Varices

Ascites

Caput medusae

Question 14

What organisms are most commonly involved in spontaneous bacterial peritonitis?

Answer 14

E. coli, Klebsiella and Streptococci

Question 15

How is hepatitis A transmitted?

Answer 15

Via the faecal/oral route and through consumption of shellfish

Question 16

How is hepatitis B spread?

Answer 16

IVDU, blood products and sexual contact

Question 17

What blood tests imply that the patient has been infected with hepatitis B?

Answer 17

Hepatitis B surface antigen (present 1-6 months following exposure)

Hepatitis B e antigen (present 1.5-3 months following cessation of the acute illness and implies increased infectivity

Hepatitis B core antigen (there at the time of the onset of infection)

Question 18

What blood tests imply that the patient has been vaccinated against hepatitis B?

Answer 18

The hepatitis B surface antigen

Question 19

What blood test implies that the patient has had a past infection of hepatitis B

Answer 19

The presence of the antibody to the hepatitis B core antigen.