Acute liver disease and fulminant hepatic failure

Question 1

what is acute liver disease?

Answer 1

rapid development of hepatic dysfunction with no prior liver disease
less than 6 months duration

Question 2

what substances does the liver metabolise?

Answer 2

protein
carbohydrates
lipids
bile acid
bilirubin
hormone and drugs

Question 3

what are the true prognostic markers in LFTs?

Answer 3

bilirubin
albumin
prothrombin time

Question 4

what does acute liver failure cause?

Answer 4

encephalopathy and prolonged coagulation (prolonged prothrombin time)

Question 5

what are the clinical features of acute liver disease?

Answer 5

none
jaundice
lethargy
nausea
anorexia
pain 
itch
arthralgia
abnormal LFTs

Question 6

what are some common causes of acute liver disease?

Answer 6

Viral - A, B, C, D E, CMV, EBV
drugs
shock liver
cholangitis
alcohol
malignancy
chronic liver disease
Always ask about paracetamol ( can raise LFTs if take a lot)

Question 7

what are some rare causes of acute liver failure

Answer 7

budd chiari (hepatic vein thrombosis)
AFLP
Cholestasis of pregnancy

Question 8

what factors can influence liver damage?

Answer 8

toxicity
- drugs
- alcohol
- viruses
- hypoperfusion
Immune
- PBC
- AIH
Genetic
- Wilsons
- Haemochromatosis
Nutrition
- NASH
- malnutrition

Question 9

what questions should be asked about possible liver disease?

Answer 9

symptoms
duration
drugs - including over the counter, herbal, food supplements
possible toxins
alcohol history
Travel, occupation, sex

Question 10

what investigations are performed for acute liver disease?

Answer 10

LFTs
prothrombin time
History and examination
US (including vascular)
Virology
Investigations of chronic liver disease
Rarely liver biopsy

Question 11

what is the standard treatment for mild acute liver disease?

Answer 11

rest, up to 3 or 6 months liver will repair
fluids
no alcohol
increase calories
reduce high fat foods
Sodium bicarbonate bath, cholestryamine or uresodeoxycholic acid for itch
Observe for FHF

Question 12

what are some metabolic factors in acute liver disease?

Answer 12

hypermatabolic state so increased reuirements but usually don’t want to eat/drink
higher rate of complications in malnourished
Oral nutrition supplements/NG feeding may be required
Monitor electrolytes….

Question 13

how/when does the liver generally affected by a drug?

Answer 13

around 6 weeks after exposure

almost any drug can affect the liver

Question 14

what is the dangerous component of paracetamol?

Answer 14

NAPQI (toxic)

causes excess free radical production by consuming glutathione

Question 15

how is paracetamol toxicity treated?

Answer 15

NAC (replaces glutathione)

Question 16

give some examples of drug classes that can cause liver disease

Answer 16

antibiotics
- co-amoxiclav
- flucox
- NSAIDs
statins (rarely)
Paracetamol containing drugs
Nurofen or "night nurse"

Question 17

what are some common causes of FHF?

Answer 17

paracetamol
fulminant viral (hep E from seafood or pork)
drugs
HBV
Non A-E

Question 18

what are some rare causes of FHF?

Answer 18

AFLP
mushrooms
malignancy
Wilsons (often young with psychiatric illness)
Budd chiari
HAV

Question 19

what are some clinical causes and complications of FHF?

Answer 19

encephalopathy
hypoglycaemia
Coagulopathy (common in paracetamol overdose)
Circulatory failure
Renal failure
Infection

Question 20

how is FHF treated?

Answer 20

supportive
inotropes and fluids
Renal replacement
manage raised ICP
- 50-60% survival
Transplant
- 65% survival
- lifelong immunosuppression

Question 21

how do you assess FHF?

Answer 21

refer quickly to consultant
repeat 6 hourly blood tests
short window of opportunity for transplant
Patients will drop a grade of encephalopathy on route to transplant