Week4: Acute and chronic liver failure

Question 1

Definition of acute liver failure

Answer 1

• presence of jaundice, encephalopathy, coagulopathy
• acute onset of rapidly progressive failure of liver function
• no known pre-existing liver disease
• fulminant: 2 weeks onset jaundice to encephalopathy
• hyper-acute: less than 7 days
• acute: 7-28 days

Question 2

Etiology of acute liver failure

Answer 2

1. Infection
   - HAV, HBV, HBV+HepD, HEV
   - rare: hep C, EBV, herpes
2. Drug reactions
   - there are greater than 400 drugs
   - 3 types: dose dependent (taking too much, e.g. acetaminophen), idiosyncratic (unpredictable), hypersensitivity
3. Autoimmune
4. Other
   - ischemic hepatitis, Wilson’s disease, acute fatty liver, vena-occlusive disease, mushroom poisoning
5. indeterminate

Question 3

King’s college criteria for poor prognosis for acute liver failure caused by acetaminophen

Answer 3

pH 6, Serum Cr > 3.3.mg/dL

grade II or IV encephalopathy (somnolent or comatose)

Question 4

King’s college criteria for poor prognosis for acute liver failure by non- acetaminophen causes

Answer 4

INR >6.0 or
age 40
non A, non B hepatitis, halothane
idiosyncratic drug reaction
dev. of encephalopathy more than 7 days after onset of jaundice
INR >3.5
Serum bili >17 mg/dL

Question 5

Complication of acute liver failrue

Answer 5

1. encephalopathy
2. cerebral edema- most common cause of death: brainstem herniation
3. coagulopathy and bleeding: poor hepatic synthetic dysf. DIC. thrombocytopenia, platelet dysfunction. FFP for active bleeding only.
4. metabolic derangements
5. infections
6. multi-system organ failure
   - CV: high CO, low SVR, hypotension, arrhythmias
   - pulm: ARDS assoc. with sepsis
   - kidney: hepatorenal syndrome.

Question 6

Chronic liver failure definition

Answer 6

• disruption of normal hepatic architecture by bands of dense fibrous tissue
• impairment of hepatic functions: bilirubin excretion and protein synthesis
• alterations in hepatic/portal blood flow and hemodynamics

Question 7

Etiologies of chronic liver failure

Answer 7

1. alcohol
2. chronic hepatitis C, B w/ or without D
3. autoimmune hepatitis
4. cholestatic liver disease: primary biliary cirrhosis or primary sclerosing cholangitis
5. inherited disorders
   - hemochromatosis
   - Wilson’s disease
   - a-1 antitrypsin
6. cryptogenic

Question 8

Pathophysiology of chronic liver failure

Answer 8

Fibrosis leading to cirrhosis leading to portal hypertension

Question 9

Child turcotte Pugh score

Answer 9

-encephalopathy stage
-ascites present?
-bilirubin level
-albumin level
-INR
Total points are added for each factor above and given a Child Class A, B, C where C has the worst prognosis

Question 10

MELD score for chronic liver failure

Answer 10

uses an equation including Cr, Bili, and INR levels to calculate a score used to estimate mean survival time

• the higher the score the shorter the survival time
• removes subjective measures of encephalopathy and ascites