Liver failure + Hepatitis Flashcards
What is liver failure?
Refers to the loss of liver function and the development of complications including coagulopathy, jaundice or encephalopathy.
Can occur:
acutely (onset of symptoms <26weeks with a previous healthy liver)
- can be divided into hyperacute (<7days), acute (8-21days), or subacute (4-26weeks).
chronically
- pt has a background of liver cirrhosis
Causes of acute liver failure?
Viral hepatitis (Hep A, B and E infections)
Drug-induced liver injury (overdose or adverse reactions to meds like paracetamol, halothane, isoniazid, certain abx)
Toxic exposures (e.g. industrial chemicals, Amanita phalloides mushrooms)
Vascular disorders (e.g. Budd-Chiari syndrome)
Vascular disorders
Causes of chronic liver failure?
Alcohol misuse (chronic alcohol consumption → cirrhosis and liver failure)
Chronic Viral Hepatitis (persistent Hep B or C virus)
NAFLD (Non-Alcoholic Fatty Liver Disease; accumulation of fat in the liver; associated with obesity and metabolic syndrome)
Autoimmune liver (e.g. autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis)
Hereditary Conditions (e.g. haemochromatosis, Wilson’s disease, and alpha-1 antitrypsin deficiency)
Presentation of acute liver failure?
Right upper quadrant pain
N+V
Malaise
Sweet smelling/musty breath (fetor)
Disorientation, slurring of speech, confusion, agitation, sleepiness, flapping tremor, personality change, coma (features of encephalopathy)
Manifestations of failure of the liver to perform its functions:
* Abnormal blood clotting
* Jaundice - uncommon unless subacute liver failure
* Low glucose
* High blood lactate
* Impaired renal function
* Acidosis
* Hyperammonaemia
* Infection
Risk factors of acute liver failure?
Hepatotoxic drugs
Contaminated food/water (Hep A and E)
Blood borne virus risks (Hep B)
- unprotected sex
- tattoos/piercings with unclean equipment
- recreational drug use -shared paraphernalia
Recreational drugs -mushrooms, ecstasy
Underlying liver disease
Investigations for liver failure?
INR (coagulopathy and establish diagnosis of liver failure)
LFTs (including albumin, bilirubin)
FBC (leucocytosis -infection; thrombocytopaenia -chronic liver disease; anaemia)
U&Es (includes sodium, potassium, urea, creatinine, eGFR)
Tests to determine cause:
- Paracetamol level (paracetamol overdose)
- Hepatitis
- Epstein-Barr virus
- Cytomegalovirus serology (viral infection)
- Iron studies (haemochromatosis)
α-1 anti-trypsin (α-1 antitrypsin deficiency)
- Caeruloplasmin level (Wilson’s disease)
- Iron studies (hereditary haemochromatosis)
- Auto-antibodies (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis)
Imaging:
- ascites present →peritoneal tap for microscopy and culture for spontaneous bacterial peritonitis.
- abdominal US
- Doppler US →Budd-Chiari syndrome
- OGD →variceal bleeding
Management of liver failure?
Resuscitate
- protect airway
- correct volume depletion, hypoglycaemia
- avoid hyponatraemia
For encephalopathy:
- grade stage of encephalopathy
- offer lactulose (help nitrogenous waste loss through the bowels; reduces encephalopathy)
- offer rifaximin (2nd line abx; reduces nitrogen forming microorganism in gut)
- offer IV mannitol (reduce cerebral oedema)
For paracetamol overdose:
- offer IV N-Acetyl Cysteine
For coagulopathy:
- IV vitamin K (helps produce coagulation factors)
- Fresh frozen plasma can be given if patient is bleeding
For spontaneous bacterial peritonitis:
- IV Piperacillin-Tazobactam (1st line broad spectrum abx)
Haemofiltration
Liver transplant if predicted poor outcome in acute liver failure.
Liver transplant (paracetamol induced):
Arterial pH <7.3 24h after ingestion OR
- Pro-thrombin time >100s
- AND creatinine >300µmol/L
- AND grade III or IV encephalopathy.
Liver transplant (non-paracetamol induced):
Prothrombin time >100s OR
Any three of:
- Drug-induced liver failure
- Age <10 or >40 years
- 1 week from 1st jaundice to encephalopathy
- Prothrombin time >50s
- Bilirubin ≥300µmol/L.
How is encephalopathy graded?
Grade 1
Altered mood and behaviour, disturbance of sleep pattern, dyspraxia
Grade 2
Drowsiness, confusion, slurring of speech, personality change
Grade 3
Incoherency, restlessness, asterixis
Grade 4
Coma
Complications of liver failure?
Bacterial infection
Fungal infection
Cerebral oedema +/-raised intracranial pressure
Bleeding
Hypoglycaemia
Multi-organ failure
What is hepatitis?
Refers to inflammation of the liver caused by a variety of infectious and non-infectious factors.
Causes of hepatitis?
Hepatitis A, B, C, D, E (5 types of viral hepatitis)
Drugs
Toxins
Alcohol
EBV
CMV
Malaria
Leptospirosis
What are the most prevalent causes of viral hepatitis in the UK?
Hepatitis A, B, and C viruses.
Which hepatitis viruses can lead to acute liver failure?
Hepatitis A and Hepatitis E
Which hepatitis viruses can lead to chronic liver failure?
Hepatitis B and Hepatitis C
Which patients experience hepatitis D?
Hepatitis D only occurs in pts infected with hepatitis B.
Presentation of acute liver failure?
Predominantly caused by Hepatitis A and E
Prodromal viral illness:
- Fever
- Malaise
- Anorexia
- Nausea and vomiting
Presentation of acute hepatitis?
Right upper quadrant pain
Jaundice
Tender hepatosplenomegaly (due to swelling of the liver capsule)
Presentation of chronic liver failure?
Hepatic encephalopathy
Jaundice
Ascites
Coagulopathy due to abnormal clotting
How is Hepatitis A transmitted? Is there a vaccine to prevent Hep A?
RNA virus transmitted via the faecal-oral route (occasionally through food sources or through anal sex).
Vaccine available.
Presentation of Hep A?
Flu-like symptoms followed by:
- jaundice
- pale stools (in some)
- dark urine
- abdominal pain
Incubation period of 2-6 weeks
Presents ONLY as an acute hepatitis with no chronic phase
Complete recovery can take up to 6 months.
Investigations of Hep A?
LFTs with ALT/AST as high as in the 1000s.
Ig M and IgG antibodies.
Management of Hep A?
Supportive management
How is Hepatitis E transmitted? Is there a vaccine to prevent Hep E? Is it dangerous in pregnancy?
RNA virus transmitted via the faecal-oral route, commonly undercooked pork.
Extremely dangerous in pregnancy, with mortality rate up to 20%.
Vaccine NOT available.
What is hepatitis B?
dsDNA virus of Hepadnaviridae family.
Causes acute hepatitis and can progress to chronic hepatitis infection.
Globally common
Incubation period usually 60-90 days.
How is Hepatitis B transmitted? Is there a vaccine to prevent Hep B?
dsDNA virus of Hepadnaviridae family transmitted via infected blood or body fluids.
E.g. vaginal/anal intercourse, transfusion, vertical transmission -pregnancy.
Vaccine available.
Presentation of Hep B?
Children:
- mostly asymptomatic
- jaundice
Adults:
- jaundice
- fever
- malaise
- viral prodrome
- darkening of urine
- lightening of stool
- ascites
- encephalopathy
Rare features:
- glomerulonephritis
- cryoglobulinaemia
- polyarteritis nodosa
If pt is worsening, consider co-infection with Hep D.
Investigations for Hep B?
HBsAg (surface antigen) –active infection; persists >6months
HBeAg (E antigen) –active viral replication; implies high infectivity
HBcAb (core antibodies) –IgM = acute infection; IgG = implies past infection or vaccination
HBV DNA (Hepatitis B virus DNA) –quantifies viral overload; monitor response to tx
Anti-HBs (Hepatitis B Surface Antibody) -indicates immunity from past infection or vaccination.
Anti-HBe (Hepatitis B e Antibody) -indicates lower infectivity; seroconversion is associated with reduced viral infection.
Biopsy
- for chronic Hep B infection
- ‘ground glass’ hepatocytes on light microscopy
Management of Hep B?
Antiviral tx:
- 1st line: pegylated interferon
- 2nd line: pegylated interferon alfa-2a
Offering symptomatic supportive treatment (rest, pain relief, and treatment of nausea and itch
Avoid alcohol
What is Hep C infection? How is it transmitted? Is there a vaccine for prevention?
RNA virus of the Flaviviridae family.
Transmitted via exchange of blood and bodily fluids.
E.g. IV drug use, blood transfusion, haemodialysis, sexual transmission, needlestick injuries, perinatal infection from infected mother.
Incubation period of 6-9 weeks.
Vaccine NOT available.
Presentation of Hep C?
Mostly asymptomatic
Can develop into chronic infection
Fever
Fatigue
Abdominal pain
N+V
Jaundice
Arthralgia (pain in the joints)
Sjogren’s syndrome
Cryoglobulinaemia
Porphyria cutanea tarda
Membranoproliferative glomerulonephritis
Investigations for Hep C?
Anti-HCV serology (may take months to become +ve; can remain positive even if the virus has been cleared)
HCV RNA (if +ve for more than two months, treat it)
FBC (check for anaemia, neutropenia, and thrombocytopenia)
U&Es (CKD can lead to extrahepatic manifestation)
LFTS (ALT, GGT)
HbA1c
TFTs (antiviral therapy can lead to thyroid dysfunction)
Ferritin (raised in Hep C)
HBsAg
HAV-IgM
HIV
STI screening
Management of Hep C?
Direct-acting antiviral (e.g. Sofosbuvir)
Sofosbuvir and daclatsavir may be used as combination therapy
Manage underlying cirrhosis.
