Liver failure (read through one) Flashcards
Define what acute liver disease is
Any insult to the liver causing damage in previously normal liver with a duration < 6 months duration
What is the treatment of acute liver disease?
- Rest, up to 3 months for recovery may be 6 months
- Fluids, NO alcohol
- Increase calories, high fat foods poorly tolerated
- Monitor and supplement K, PO4 and Mg
- For itch – cholestyramine
- Observation for Fulminant Hepatic Failure (FHF)
What are the 2 types of liver failure?
- Acute hepatic failure = defined as causing encephalopathy and prolonged coagulation (synmom is fulminant hepatic failue)
- Acute-on-chronic hepatic failure = decompensation of chronic liver disease
What are the causes of liver failure ?
- Infections - Viral hepatitis (esp B, C & CMV)
- Drugs - paracetamol overdose, halothane, isoniazid
- Vascular - budd chiari syndrome, veno-occulsive disease
- Alcohol
- NAFLD or fatty liver of pregnancy
- PBC
- Haemochromatosis
- Autoimmune hepatitis
- A1AT deficiency
- Wilsons disease
- Malignancy
- HELLP syndrome
What are the clinical features of liver failure ?
- Jaundice
- Coagulopathy: raised prothrombin time
- Hypoalbuminaemia
- Hepatic encephalopathy
- Renal failure is common (‘hepatorenal syndrome’)
- Signs of chronic liver disease suggests acute-on-chronic hepatic failure
What is the management of liver failure ?
- ABCDE & monitor vitals
- Insert NG tube
- Give 10% glucose to avoid hypoglycaemia
- If malnourished or history of alcohol excess give thamine & folate
- Give calcium & vitamin D supplements as Osteoporosis and osteomalacia are common
- If seizures give lorazepam
- Haemofiltration of haemodialysis if renal failure develops
- Treat cause if known
What complications can develop from liver failure and how are they treated ?
- Cerebral oedema - Tx = IV mannitol & hyperventilate
- Ascites - Tx = Restrict fluid, low salt-diet & diuretics
- Bleeding - Tx = Vitamin K +/- Platelets, FFP or blood PRN
- Hypoglycaemia - give 10% glucose and check BG
- Encephalopathy - avoid sedatives, give lactulose + regular enemas
- Circulatory failure
- Renal failure
- Infection
What is hepatic encephalopathy ?
- A decline in brain function that occurs as a result of severe liver disease.
- In this condition, your liver can’t adequately remove toxins from your blood. This causes a build-up of nitrogenous waste (ammonia) in your bloodstream, which can cross the blood-brain-barrier and lead to brain damage
What are the clinical features of hepatic encephalopathy ?
- Confusion, altered GCS (any neruology)
- Asterix: ‘liver flap’, arrhythmic negative myoclonus with a frequency of 3-5 Hz
- Constructional apraxia: inability to draw a 5-pointed star
- Triphasic slow waves on EEG
- Raised ammonia level (not commonly measured anymore)
How is hepatic encephalopathy graded ?
- Grade I: Irritability
- Grade II: Confusion, inappropriate behaviour
- Grade III: Incoherent, restless
- Grade IV: Coma
How is hepatic encephalopathy treated?
- Treat any underlying precipitating cause
- 1st line = lactulose (initial treatment) + rifaximin for secondary prophylaxis
How is ascites diagnosed ?
- OE: dullness to percussion and shifting dullness
- Ix: US
What is the treatment of ascites ?
Fluid restriction + low sodium diet
- 1st line = aldosterone antagnosits - spironolactone
- 2nd line = add loop diuretic furosemide
+ Prophylactic Abx ciprofloxacin or norfloxacin to reduce the risk of spontaneous bacterial peritonitis if acitic protein ≤ 15 g/litre , until the ascites has resolved
If tense acites then do therapeutic abdominal paracentesis (drainage)
May end up needing TIPS
What is spontaneous bacterial peritionitis (SBP) ?
A form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
What are the clinical features suggestive of spontaneous bacterial peritionitis?
- Ascites
- Abdominal pain
- Fever
