Acute and Chronic Liver Failure

Question 1

In liver failure, the liver loses it ability to…

Answer 1

regenerate / repair

Question 2

In acute liver failure, liver injury is accompanied with (3 things) in a patient with a previously normal liver

Answer 2

HE
Jaundice
Coagulopathy
(ascites)

Question 3

What is HE?

Answer 3

Hepatic encephalopathy
Impairment of brain function, associated with cirrhosis. Caused by elevated levels of ammonia in the blood.

Question 4

What are symptoms of HE?

Answer 4

Changes in personality or behaviour
Impaired motor skill
Altered sleep patterns
Speech and writing changes
Fluctuations in consciousness

Question 5

What defines coagulopathy?

Answer 5

An INR over 1.5

Question 6

What is Fulminant liver failure?

Answer 6

aka Acute liver failure:
Rare syndrome of massive hepatocyte necrosis.
Histologically, multiacinar necrosis.
Develops within days to weeks

Question 7

What classifies fulminant liver disease as hyperacute?

Answer 7

HE develops within 7 days of jaundice

Question 8

What classifies fulminant liver disease as acute?

Answer 8

HE develops within 8-28 days of jaundice

Question 9

What classifies fulminant liver disease as subacute?

Answer 9

HE develops within 5-26 weeks

Question 10

What is the most common cause of fulminant liver failure?

Answer 10

Paracetamol overdose

Question 11

What is the term used for an abrupt decline in patient with chronic liver failure symptoms?

Answer 11

Acute on chronic liver failure

Question 12

What is chronic liver failure?

Answer 12

Patient with a progressive history of liver disease

Question 13

Hepatitis leads to…

Answer 13

fibrosis

Question 14

Fibrosis of the liver leads to…

Answer 14

Compensated cirrhosis

Question 15

Compensated cirrhosis can progress to…

Answer 15

Uncompensated cirrhosis (ESLF)

Question 16

What does ESLF stand for?

Answer 16

End Stage Liver Failure

Question 17

What are some causes of fulminant liver failure?

Answer 17

Hepatitis A, B or E
CMV
EBV
Autoimmune hepatitis
Paracetamol, alcohol, ecstasy
HCC (hepatocellular carcinoma)
Wilson’s
Haemochromatosis
A1ATD
Budd Chiari

Question 18

What is Haemochromatosis?

Answer 18

Hereditary disorder, increased absorption of iron leading to gradual accumulation of iron in organs and tissues. Organ damage.
Symptoms include fatigue, joint pain, abdominal pain and hepatomegaly.

Question 19

What is A1ATD?

Answer 19

Alpha-1 Antitrypsin Deficiency
Genetic disorder of abnormal or insufficient A1AT which normally protects lungs from damage by enzymes released by immune cells.
build up of A1ATD in liver can cause cirrhosis

Question 20

What is Budd Chiari?

Answer 20

Rare disorder characterised by obstruction or blockage of the hepatic veins that drain the liver causing congestion and liver damage. Often presents with ascites, hepatomegaly and jaundice.

Question 21

What are the 3 main symptoms of Fulminant liver disease?

Answer 21

Jaundice
Coagulopathy
HE

Question 22

What is used to grade the HE?

Answer 22

West Haven criteria, grades 1-4

Question 23

What is grade 1 HE?

Answer 23

Altered mood
Sleep issues

Question 24

What is grade 2 HE?

Answer 24

Lethargy
Mild confusion
Asterixis (aka liver flap, neurological involuntary flapping of hands)

Question 25

What is grade 3 HE?

Answer 25

Marked confusion Somnolent (drowsy, very quiet)

Question 26

What is grade 4 HE?

Answer 26

Comatose

Question 27

What symptoms may be seen in acute liver failure but more likely in chronic liver failure?

Answer 27

Spider naevi Fetor hepaticus Caput medusae Dupuytren's contracture

Question 28

What is spider naevi?

Answer 28

Small dilated blood vessel near surface of skin, red or blue vascular lesions with central arteriole surrounded by smaller capillaries. Commonly found on face, neck, upper chest and arms. Caused by changes in blood flow and increased levels of oestrogen

Question 29

What is fetor hepaticus?

Answer 29

Distinctive musty, sweet or slightly faecal odour of breath associated with severe liver disease due to liver's inability to detoxify harmful substances.

Question 30

What is caput medusae?

Answer 30

Appearance of dilated and engorged veins that radiate from the umbilicus outward across the abdomen. Looks like Medusa. Caused by increased pressure in portal venous system so collateral vessels used.

Question 31

What is Dupuytren's contracture?

Answer 31

One or more finger bend towards palm and can't straighten properly. Thickened and tightened palmar fascia with nodules and fibrous chords forming, pulling fingers bent.

Question 32

How do you diagnose fulminant liver disease?

Answer 32

LFTs: Raised bilirubin Lowered albumin Raised PT/INR Raised serum AST and ALT Raised NH3 Lowered glucose If paracetamol overdose then raised paracetamol Imaging: EEG (electroencephalogram) to grade HE Abdominal USS (ultrasound scan) to check Budd Chiari Microbiology: To rule out infections (blood culture, urine culture and ascetic tap)

Question 33

Why are there lower glucose levels in liver disease?

Answer 33

Impaired glycogen storage and release Decreased gluconeogenesis Altered levels of insulin and glucagon

Question 34

Where is glucagon made?

Answer 34

Alpha cells of islets of Langerhans in the pancreas

Question 35

Where is insulin made?

Answer 35

Beta cells of islets of Langerhans in the pancreas

Question 36

How do you treat fulminant liver disease?

Answer 36

ITU Remember ABCDE Give fluids Analgesia Treat underlying cause and complications

Question 37

What do you give for a paracetamol overdose?

Answer 37

Activated charcoal then N acetyl cysteine (NAC) The charcoal can help to absorb the paracetamol in the stomach preventing it absorption into the bloodstream NAC works by replenishing deplete glutathione, a substance in the liver that helps to detoxify paracetamol.

Question 38

How do you treat increased ICP (intra-cranial pressure)?

Answer 38

Mannitol by IV

Question 39

How do you treat HE?

Answer 39

Lactulose (helps increase ammonia excretion)

Question 40

How do you treat ascites?

Answer 40

Diuretics (especially spironolactone)

Question 41

How do you treat a haemorrhage?

Answer 41

Vitamin K

Question 42

How do you treat sepsis?

Answer 42

Sepsis 6: High flow oxygen Obtain blood cultures IV antibiotics IV fluids Measure serum lactate Monitor urine output

Question 43

Chronic liver failure is a progressive liver disease over _ months due to repeated liver insults

Answer 43

6

Question 44

What causes chronic liver failure?

Answer 44

Alcoholic liver disease (most common) Non-alcoholic fatty liver disease Viral eg hepatitis B, C or D also metabolic, budd chiari, drugs, autoimmune, PBC and PSC

Question 45

What does PBC stand for?

Answer 45

Primary Biliary cirrhosis

Question 46

What does PSC stand for?

Answer 46

Primary sclerosing cholangitis

Question 47

What are risk factors for chronic liver disease?

Answer 47

Alcohol Obesity T2DM Drugs Inherited metabolic disease Existing autoimmunity

Question 48

What is used to assess the prognosis and extent of treatment required for chronic liver failure

Answer 48

Child-Pugh Score; A,B or C Looking at bilirubin levels, ascites presence, serum albumin, PT/INR and hepatic encephalopathy

Question 49

What is class A chronic liver failure?

Answer 49

100% 1 year survival rate

Question 50

What is class B chronic liver failure?

Answer 50

80% 1 year survival rate

Question 51

What is class C chronic liver failure?

Answer 51

45% 1 year survival rate

Question 52

ESLF (decompensated cirrhosis) is a huge risk factor for developing...

Answer 52

Hepatocellular carcinoma (HCC)

Question 53

What is used to stratify the severity of ESLD for transplant planning?

Answer 53

MELD score

Question 54

What are symptoms of chronic liver failure?

Answer 54

Jaundice Ascites HE portal hypertension and oesophageal varices Caput medusae Spider naevi Fetor hepaticus Palmar erythema Gynecomastia Clubbing Dupuytren's contracture

Question 55

What is fetor hepaticus?

Answer 55

Characteristic bad breath due to liver failure

Question 56

What is palmar erythema?

Answer 56

Palms of hands turn red (not swollen, painful or itchy)

Question 57

What is gynecomastia?

Answer 57

Enlargement of a man's breasts usually due to hormone imbalance

Question 58

What is Dupuytren's contracture?

Answer 58

One or more fingers are bent in towards the palm due to abnormal thickening of tissue

Question 59

What investigations would be carried out for chronic liver disease?

Answer 59

Liver biopsy (gold standard) - to determine extent. How much fibrosis vs cirrhosis. LFT Ultrasound scan Ascetics tap culture

Question 60

What is the treatment for chronic liver failure?

Answer 60

Prevent progression: Less alcohol, lower BMI, avoid drugs Consider liver transplant (if decompensated) Manage complications: HE with lactulose Ascites with diuretics Oesophageal varices ruptures SBP (spontaneous bacterial peritonitis, infection in ascetic fluid)