Module 3 Chapter 10. Acute Liver Failure and Acute on Chronic Liver Failure

Question 1

define ALF

Answer 1

1. INR over 1.5
2. encephalopathy of any degree
3. in a patient without preexisting cirrhosis
4. illness has lasted less than 26 weeks (acute)

Question 2

leading cause of ALF in north america

Answer 2

acetaminophen

Question 3

treatment of acetaminophen overdose

Answer 3

NAC

Question 4

mushroom poisoning and treatment

Answer 4

amanita phalloides found in late summer. Produces anticholinergic symptoms and ALF 4-8 days after ingestion. treatment is with penicillin G or silibinin (milk thistle)

Question 5

which viral diseases can cause ALF

Answer 5

HAV, HBV, HCV, HDV (in HbsAg+), HEV

Question 6

young patient with hemolytic anemia (copper released from liver is toxic to red blood cells) with high bilirubin (↑ unconjugated) and low ALP . KF rings are very helpful with diagnosis as ceruloplasmin is not always low and 24 hour urine
copper can be falsely high from other causes of ALF
Diagnosis and treatment?

Answer 6

Wilson’s disease. need liver transplant, almost none survive without LT.

Question 7

young patients (more likely in women) and may have positive ANA or ASMA
and elevated IgG

o Liver biopsy (done via transjugular route) is needed to establish the diagnosis

diagnosis and treatment?

Answer 7

probably AIH, treat with prednisone

Question 8

following cardiovascular collapse, an ischemic event called ___ ___ ___ can occur in the liver. What happens?

Answer 8

Budd Chiari Syndrom. Thrombosis of the hepatic veins (outflow of the liver). Patients present with RUQ pain, jaundice, weight gain and ascites.

ONLY ALF where ascites is a prominent feature.

Associated with hypercoagulable states such as thrombophilia, malignancy or connective
tissue diseases

treatment is with anticoagulation or trans jugular intrahepatic portosystemic shunt (TIPS).– but gotta watch out for encephalopathy.

Question 9

2 conditions in pregnancy which can result in ALF

Answer 9

1. acute fatty liver of pregnancy
2. HELLP (hemolysis, elevated liver enzymes and low platelets)– patient with pre-exlampsia. treatment is immediate delivery of the baby.

Question 10

top 4 causes of ALF in USA

Answer 10

1. tylenol
2. shock/ischemia/budd chiari syndrome.
3. HAV (Hepatitis)
4. Pregnancy.

Question 11

initial testing when suspecting liver failure. prognosis? for defining etiology?

Answer 11

1. liver enzymes
2. bilirubin, albumin, INR,
3. electrolytes,
4. creatinine,
5. lipase.

o For prognosis = INR, ammonia (arterial), arterial blood gas (ABG) for pH, lactate

For defining etiology = acetaminophen level, toxicology screen, IgM anti-HAV, HBsAg, IgM
anti-HBc, anti-HCV, anti-HDV, anti-HEV, ceruloplasmin, ANA, ASMA, IgG, pregnancy test,
Doppler US of liver

For pre-liver transplant evaluation = CBC, type & screen, HIV testing

Question 12

what tests for liver function tests

Answer 12

bilirubin, albumin, INR,

Question 13

kings college criteria for LT for someone who didn’t take tylenol

Answer 13

1. INR>6.5 with HE
OR
2. any 3 of 5 WITH HE
-Age 10-40
- Bilirubin >300
-coagulation INR>3.5
- Duration Jaundice to HE >7 days
- etiology Non A-E, other drug.

Question 14

kings college criteria for LT for someone who took tylenol

Answer 14

1. Lactate >3,5
OR
2. pH <7.3, or lactate >3
OR
3. Grade III or IV HE and 
INR>6.5
Creatinine >300

Question 15

outline the survival outcomes based on grade of encephalopathy

Answer 15

 I = 70%
 II = 60%
 III = 40%
 IV (coma) = 20%

Question 16

explain hematological issues with ALF

Answer 16

coagulopathy, DIC

Question 17

explain neurologic issues with ALF

Answer 17

hepatic encephalopathy and cerebral edema (leading cause of death)

Question 18

explain hemodynamic issue with ALF

Answer 18

shock

Question 19

explain metabolic issues with ALF

Answer 19

acidosis, alkalosis, hypoglycaemia, hypophosphatemia

Question 20

T/F lactulose helps with ALF induced hepatic encephalopathy.

Answer 20

false. lactulose helps with HE only with cirrhosis

Question 21

how can high ICP be treated?

Answer 21

High ICP can be treated with hypernatremia, hypothermia and hemofiltration (HHH) using
continuous venous hemodialysis (CVHD)

Question 22

REFER TO DRAWN OUT SCHEME IN NOTES FOR ALF MANAGEMENT: 4E’s and 3H’s

Answer 22

see pics

Question 23

what is acute on chronic liver failure (ACLF)

Answer 23

syndrome of acute decompensation of a chronic liver disease.
- associated with organ failure including liver failure, kidney dysfunction, brain dysfunction from hepatic encephalopathy, coagulation abnormalities, circulations and respiratory failure.

high 1 month mortality ( looks like ALF)

Question 24

etiology of ACLF

Answer 24

• Alcohol and chronic viral hepatitis are most common underlying liver problem
• Triggers include sepsis, active alcohol consumption, relapse of viral hepatitis, GI bleeding
o No identifiable cause is found in 20-40%
• Pathogenesis involves an excessive systemic inflammatory response

Question 25

scoring systems to assess acute on chronic liver failure

Answer 25

MELD and child Pugh. ACLF grade is based on number of organ failures.

Question 26

management of ACLF

Answer 26

no specific therapy: must identify and treat precipitating cause. Support of organ failure in ICU.

• prognosis is evident by day 3-7. Consider liver transplantation. Liver support systems have not demonstrated clear benefit.