Week 11- Liver Failure

Question 1

What is the main pathophysiological characteristic of jaundice

Answer 1

High levels of bilirubin

Question 2

What is the normal level of plasma BR?

Answer 2

17 micro ml

Question 3

What happens when BR exceeds 30 micro ml?

Answer 3

Yellow sclera and mucous membranes

Question 4

What happens when BR exceeds 34 micro ml?

Answer 4

Yellow skin

Question 5

What is cholestasis?

Answer 5

Slow bile flow/ cessation of bile flow

Question 6

Does jaundice always indicate cholestasis?

Answer 6

No

Question 7

What are pre hepatic causes of jaundice?

Answer 7

Haemolysis, ineffective erythropoiesis, massive transfusion etc reducing bile production

Question 8

What are intra hepatic causes of jaundice?

Answer 8

Problems with conjugation of bilirubin, decreased uptake, decreased secretion, reduced outflow (cholestasis), liver failure

Question 9

What are post hepatic causes of jaundice?

Answer 9

Gallstones, tumors etc reducing extra hepatic outflow

Question 10

What is liver disease from pathophysiological point of view?

Answer 10

Hepatocyte death rate > hepatocyte regeneration

Question 11

How does cell death occur in liver failure?

Answer 11

Can apoptosis or necrosis (or a combination)

Question 12

How serious is liver failure?

Answer 12

Very serious, can lead to multiple organ failure and coma

Question 13

What are the 2 types of acute liver failure? Define them

Answer 13

Fulminant hepatic failure= rapid development in less than 8 weeks of severe acute liver injury, impaired synthetic function, encephalopathy, previously normal liver
Sub fulminant= same but develops in less than 6 monthds

Question 14

What is chronic liver failure?

Answer 14

Over years, cirrhosis

Question 15

What are the 2 common causes of liver failure and where are they most common?

Answer 15

Toxins (western world): Paracetamol, bacillus cereus

Inflammation (eastern world): Hep E (India) and chronic Hep B exacerbations (Hong Kong)

Question 16

What are some other uncommon causes of acute liver failure?

Answer 16

Disease of pregnancy
Idiosyncratic drug reactions
Vascular disease
Metabolic disease

Question 17

What are causes of chronic liver failure?

Answer 17

Inflammation
Alcohol abuse
Side effects of drugs
Cardiovascular disease
Inherited disease

Question 18

What is the consequence during hepatocyte failure of lack of production of clotting factors?

Answer 18

Coagulopathy and bleeding

Question 19

What is the consequence during hepatocyte failure of lack of protein synthesis?

Answer 19

Ascites

Question 20

What is the consequence during hepatocyte failure of lack of detoxification?

Answer 20

Encephalopathy and cerebral oedema

Question 21

What is the consequence during hepatocyte failure of lack of glycogen storage?

Answer 21

Hypoglycaemia

Question 22

What is the consequence during hepatocyte failure of lack of immunological function and globulin production?

Answer 22

Increased susceptibility to infection

Question 23

What is the consequence during hepatocyte failure of lack of maintenance of homeostasis?

Answer 23

Circulatory collapse, renal failure

Question 24

Why do ascites arise?

Answer 24

Reduced albumin

Question 25

What are the consequences of cholestasis pathophysiologically?

Answer 25

Aggravates bleeding tendency, reduced bile salts results in reduced absorption of vit K and its carboxylation

Question 26

What are the clinical consequences of cholestasis?

Answer 26

``` Increased BR leads to jaundice Pruritus (itching) Cholesterol deposition Malabsorption Cholangitis ```

Question 27

What condition associated with blood cell count occurs due to liver failure and why?

Answer 27

Thrombocytpenia due to splenomegaly

Question 28

What does exudative enteropathy in liver failure lead to?

Answer 28

``` Increased ascites (loss of albumin from plasma) Increased liberation of ammonia (toxic to the brain) ```

Question 29

What makes ascites worse during liver failure?

Answer 29

Reduced lymphatic flow

Question 30

What are pre hepatic causes of portal hypertension?

Answer 30

PV thrombosis

Question 31

What are intra hepatic causes of portal hypertension?

Answer 31

``` Presinusoidal= chronic hepatitis, granulomas Sinusoidal= acute hepatitis, alcohol, fatty liver, toxins Postsinusoidal= venous occlusive disease of venules and small veins ```

Question 32

What are consequences of portal hypertension?

Answer 32

Malabsorption Splenomegaly- anaemia and thrombocytopenia Vasodilators- glucagon, prostacyclins etc lead to hyperperfusion of abdominal organs and varices Encephalopathy- toxins from the intestine get into the CNS Varices- thin walled collateral vessels and reduced clotting factors w thrombocytopenia lead to bleeding

Question 33

What is hepatic encephalopathy?

Answer 33

Apathy, memory gaps, tremor and liver coma

Question 34

What is clinically observable in someone with hepatic encephalopathy?

Answer 34

Hyperammonaemia (liver cant NH3 or NH4+ to ammonia) Hypokalaemia Toxins (bypass the liver) False transmitters

Question 35

How is the severity of liver failure measured?

Answer 35

Via the Child- Pugh score

Question 36

What total bilirubin level gives 1/2/3 points on the Child- Pugh score?

Answer 36

1: <34 2: 35-51 3: >51

Question 37

What serum bilirubin level gives 1/2/3 points on the Child- Pugh score?

Answer 37

1: >35 2: 28-35 3: <28

Question 38

What INR level gives 1/2/3 points on the Child- Pugh score?

Answer 38

1: <1.7 2: 1.71- 2.3 3: >2.3

Question 39

What ascites level gives 1/2/3 points on the Child- Pugh score?

Answer 39

1: none 2: slight/surpressed with medication 3: moderate despite diuretics/refractory

Question 40

What hepatic encephalopathy level gives 1/2/3 points on the Child- Pugh score?

Answer 40

1: none 2: grade I-II 3: grade III-IV

Question 41

How is the Child Pugh scale used?

Answer 41

Class A: 5-6 points (expectancy of 15-20 yrs) Class B: 7-9 points (transplant candidate) Class C: 10-15 points (life expectancy 1-3 months)

Question 42

What treatment is offered to those with liver failure for encephalopathy?

Answer 42

Reduce protein intake | Phosphate enemas/lactulose

Question 43

What treatment is offered to those with liver failure for hypoglycaemia?

Answer 43

Infusion 10-50% dextrose

Question 44

What treatment is offered to those with liver failure for hypoglycalcaemia?

Answer 44

10ml 10% gluconate

Question 45

What treatment is offered to those with liver failure for renal failure?

Answer 45

Haemofiltration

Question 46

What treatment is offered to those with liver failure for respiratory failure?

Answer 46

Ventilation

Question 47

What treatment is offered to those with liver failure for hypotension?

Answer 47

Albumin and vasoconstrictors

Question 48

What treatment is offered to those with liver failure for infection?

Answer 48

Frequent cultures | Antibiotics

Question 49

What treatment is offered to those with liver failure for bleeding?

Answer 49

Vit K FFP Platelets

Question 50

What are causes of death from liver failure?

Answer 50

``` Bacterial and fungal infections Circulatory instability Cerebral oedema Renal failure Respiratory failure Acid/base or electrolyte disturbance Coagulopathy ```

Question 51

What are some liver support devices used to treat liver failure?

Answer 51

Artficial albumin exchange system- based on selective removal of albumin bound toxins from blood Bioartificial- hepatocytes in culture Hepatocyte transplantation

Question 52

What are the main indications for liver transplantation

Answer 52

Cirrhosis Cancer Cholestatic disease

Question 53

What is required lifelong after liver transplation

Answer 53

Immunosurpression

Question 54

What is the 5 year survival rate of liver transplants?

Answer 54

60-80% and no recurrence of disease