Liver Failure

Question 1

Definition of acute liver failure?

Answer 1

• No underlying liver condition
• <26 weeks.
• INR > 1.5
• Encephalopathy

Question 2

Main ddx for liver failure in the 0-1 week timeframe?

Answer 2

Apap, Hep A

Question 3

Main ddx for liver failure in the 1-4 week timeframe?

Answer 3

Hep B

Question 4

Main ddx for liver failure in the 4-26 week timeframe?

Answer 4

Non-Apap Rx

Question 5

4 main Ddx for LFTs > 10,000

Answer 5

• Ischemia
• Mushrooms
• Acute viral infection
• Apap

Question 6

Buzzword: Mushroom hunter, liver failure.

Disease and Tx?

Answer 6

Amanita toxicity (“Death-Cap Mushroom”). Tx is charcoal, PCN-G, Silibinin

Question 7

Buzzword: Pregnant, liver failure.

Disease and Tx?

Answer 7

HELLP, Acute fatty liver of pregnancy. Tx is delivery.

Question 8

Buzzword: Travel to endemic region, liver failure.

Disease and Tx?

Answer 8

Acute Hep B. Tx is entacavir.

Question 9

Buzzword: immunosuppressed, headache for 2 weeks, liver failure.
Disease and Tx?

Answer 9

HSV. Tx is acyclovir.

Question 10

Buzzword: young, ulcerative colitis, liver failure.

Disease and Tx?

Answer 10

Autoimmune hepatitis. Tx is steroids. (Test with ANA, Anti-Smooth muscle antibodies).

Question 11

Buzzword: gold ring around eye, liver failure.

Disease and Tx?

Answer 11

Wilson Dz / Kaiser-Fleischer rings. Tx w/ transplant or plasma exchange. Test with ceruloplasmin, Ur/Ser copper levels.

Question 12

Buzzword: hypercoaguable, CA, liver failure.

Disease and Tx?

Answer 12

Budd-Chiari. Tx is AC, TIPS.

Question 13

Role of NAC in acute hepatitis?

Answer 13

Mortality benefit if in HE grade I-II (not III-IV). Any cause.

Question 14

Antibiotic culprits in DILI?

Answer 14

Anti-TB (INH). Bactrim. Macrobic. Azoles.

Question 15

Herbs causing DILI?

Answer 15

Skull-Cap mushrooms (Amanita), kava, mahuang

Question 16

Drugs causing DILI?

Answer 16

• Antibiotics (INH, bactrim, macrobid, azoles)
• Phenytoin
• Herbs (Skull-cap, Kava, Mahuang)

Question 17

Grade hepatic encephalopathy.

Answer 17

0=Nl.
1 = subtle. Mild confusion, short attention span.
2 = disoriented, personality changes, inappropirate behavior.
3 = stuporous, but arousable.
4 = overt coma.

Question 18

5 indications for referral for liver transplant?

Answer 18

• INR > 1.8 (or INR > 3 in Apap)
• acidosis
• hypoglycemia
• encephalopathy
• AKI

Question 19

Discriminant Function score for severe alcoholic hepatitis?

Answer 19

DF > 32

Question 20

Discriminant Function equation (EtOH Hepatitis)?

Answer 20

DF = 4.6 * (PT - Normal PT) * Bilirubin

Question 21

How to use Lili score in acute liver failure?

Answer 21

Used in acute EtOH failure. If using pentoxifylline or prednisolone, check Lili score at outset & at day 7. If no improvement, stop steroids.

Question 22

Dx of SBP?

Answer 22

Asicites fluid with PMNs >=250, and (+) Gm stain.

Question 23

Abx Tx of SBP if PCN-allergic?

Answer 23

FQ

Question 24

Tx of SBP?

Answer 24

Abx (3rd gen Cephalosporin) + Albumin

Question 25

Albumin regimen for SBP?

Answer 25

1.5g/kg at Dx, 1g/kg on day 3.

Question 26

1st line drug for acute liver failure decompensation induced hypotension?

Answer 26

Levophed

Question 27

Albumin regimen after large volume paracentesis?

Answer 27

5g Albumin per liter fluid removed, after 5L.

Question 28

Criteria for hepatorenal syndrome?

Answer 28

• Cr > 1.5
• No change after Albumin 1g/kg
• Off diuretics for 2 days
• No nephrotoxins, shock, AbNl Ua or hypovoleumia.

Question 29

Difference between type 1 vs type 2 hepatorenal syndrome?

Answer 29

1. Rapid. Cr double over 2 weeks, or 50% reduced Cr clearance. 2 week survival.
2. Stable, slower progression over months. 6 month survival.

Question 30

Tx of hepatorenal syndrome?

Answer 30

• Albumin 1g/kg
• Levo to increase MAP 10-15
• Midodrine & octreotide to expand blood volume