Acute Liver Failure

Question 1

What happens to the liver when it fails? What can’t it do?

Answer 1

Liver loses regeneration/repair ability, irreversibly damaged, decompensated

Question 2

What is the definition of acute liver failure?

Answer 2

Liver injury accompanied with HE, JAUNDICE & COAGULOPATHY (& ascites) in a patient with previously normal liver

Question 3

What does HE stand for?
What is it?

Answer 3

Hepatic encephalopathy
Accumulation of NH3 crossing BBB and accumulates in CNS

Question 4

What is the coagulopathy for someone in acute liver failure?

Answer 4

> 1.5 INR

Question 5

What is a fulminant live failure?

Answer 5

Rare syndrome of massive hepatocyte necrosis

Question 6

What is seen on histology for Fulminant liver failure?

Answer 6

Multiacinar necrosis

Question 7

What is the duration of hyperacute, acute and subacute HE within jaundice?

Answer 7

Hyperacute = HE within 7 days of jaundice

Acute = 8-28 days HE within jaundice

Subacute = 5-26 weeks

Question 8

What is the most common cause of fulminant liver failure?

Answer 8

Paracetamol overdose (50% cases in UK)

Question 9

What is acute onset of chronic liver failure?

Answer 9

Abrupt decline in Px with chronic liver symptoms

Question 10

What Is chronic liver failure?

Answer 10

Patient with progressive history of liver disease
Hepatitis –> fibrosis –> Conpensated cirrhosis –> Decompensated cirrhosis (ESLF)

Question 11

Causes of Acute liver failure?

Answer 11

Viral = Hep A,B,E ; CMV; EBV
Autoimmune Hep
Drugs = paracetamol, alcohol, ecstasy
HCC (hepatocellular carcinoma)
Metabolic = Wilsons, haemochromatosis, A1ATD
Budd Chiari syndrome = obstruction of hepatic venous outflow

Question 12

Symptoms of ALF
Acute presentation?

Answer 12

Jaundice
Coagulopathy
HE

Question 13

What is used to grade HE?

Answer 13

West Haven criteria
grade 1-4

Question 14

What is West haven criteria?

Answer 14

1. Altered mood/behaviour, sleep issues
2. Lethargy, mild confusion, ASTERIXIS (liver flap, hand flap like bird)
3. Marked confusion, somnolent (very quiet)
4. Coma

Question 15

What are some other symptoms of acute liver failure? (more seen in chronic)

Answer 15

Spider Naevi (cluster of small red BV under skin)
Fetor hepaticus (musty sweet rotten egg and garlic breath)
Caput medusae (distended abdo BVs)
Dupuytren’s contracture

Question 16

Diagnosis of Acute liver failure
tests and what’s seen?

Answer 16

Bloods:
LFTs (high bilirubin, low albumin, high PT/INR)
High serum AST + ALP, High NH3, low glucose

Imaging:
EEG to grade HE
Abdominal US to check Budd chiari
(Biopsy usually not required)

Microbiology to rule out infections:
Blood culture
Urine culture
Ascitic tap

Question 17

What would be seen in bloods if symptoms due to paracetamol overdose or hep?

Answer 17

High paracetamol levels if paracetamol overdose
or serology for hep

Question 18

Acute treatment for acute liver failure?

Answer 18

ITU
ABCDE
Fluid
Analgesia
Treat underlying cause + complication

Question 19

What would be used to treat a paracetamol overdose?

Answer 19

Activated charcoal then N Acetyl cysteine

Question 20

What complications of acute liver failure could occur?

Answer 20

High ICP (Increased intracranial pressure)
HE
Ascites
Haemorrhage
Sepsis

Question 21

Treatments for:
High ICP (Increased intracranial pressure)
HE
Ascites
Haemorrhage
Sepsis

Answer 21

IV Mannitol
Lactulose (increased NH3 excretion)
Diuretics (esp spironolactone)
Vit K
Sepsis 6 bundle