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Hepatology > Acute Liver Failure > Flashcards

Acute Liver Failure Flashcards

1
Q

What is acute liver failure?

A

Clinical manifestation of sudden and severe hepatic injury which leads to encephalopathy , coagulopathy and frequent multi organ failure

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2
Q

What are the essential components of ALF?

A

Encephalopathy
Coagulopathy (INR more or equal to 1.5)
No pre existing liver disease
Illness <26weeks

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3
Q

What are the 3 presentations of fulminant liver failure?

A

Hyperacute, acute, subacute

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4
Q

Give the features of Hyperacute fulminant liver failure

A

Time from jaundice to encephalopathy is 0-1 week
Severity of encephalopathy is +++
Severity of jaundice is +
Degree of intracranial hpt +++
Survival rate without transplant:good

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5
Q

What typically causes hyperacute fulimant liver failure?

A
  • Paracetamol OD
  • Hep A and E
  • Ischaemic hepatitis
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6
Q

Features of acute fulminant liver failure

A

Time from jaundice to encephalopathy 1-4 weeks
Severity of coagulopathy ++
Severity of jaundice ++
Degree of intracranial hpt ++
Survival rate without emergency liver transplant is moderate

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7
Q

What causes acute fulminant liver failure

A

Acute hep B

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8
Q

What are the features of subacute liver failure

A

Time from jaundice to encephalopathy is 4-12 weeks
Severity of coagulopathy +
Severity of jaundice +++
Degree of intracranial hpt +/-
Survival rate without liver transplant: poor

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9
Q

What causes subacute liver failure

A

Idiosyncratic, DILI, cryptogenislc

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10
Q

What aetiologies does acute liver failure have?

A

Viral hepatitis: HAV, HBV, HEV, HSV 1/2, VZV
Drugs and toxins: Paracetamol, tb drugs, arvs, antimicrobials
Pregnancy related liver disease
Ischaemic shock
Acute budd-chiari syndrome
Autoimmune hepatitis

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11
Q

True or false: acute liver failure is caused by only one factor and does not interact with other factors

A

False, factors like Etiology, other host factors like sex and age, host genetocs and the hepatic environment acts together to cause ALF

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12
Q

What is the 1st step in management of ALF

A

Early diagnosis + transfer to appropriate care:
INR more or equal to 1.5, altered mental status with no pre existing liver disease needs transfer to hospital

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13
Q

What must you give a patient with early warning signs of cerebral oedema

A

IVI mannittol prior to transfer and during transfer give IVI dextrose to maintain euglycaemia

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14
Q

What is step 2 of management of ALF

A

Decision to give N-acetylcysteine if paracaetamol hepatotoxicity is suspected

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15
Q

What is stage 3 of management of ALF

A

Look for necessity to transfer to liver transplant unit:
INR>2 or grade 2 encephalopathy
High risk patients: <10/>40
Aetiologies with poor prognosis

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16
Q

What is the 4th step in management of alf

A

Listing for emergency liver transplant using kings college criteria

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17
Q

What are the required factors needed for emergency liver transplant in a suspected Paracetamol induced ALF according to kings criteria

A

Arterial pH <7.30 after fluid resus
Serum lactate >3.5mmol/l at 4hr or >3mmol/l at 12hr

Or all of the following:
INR>6.5
serum creatinine >300
Grade 3/4 hepatic encephalopathy

18
Q

What are the requirements for a non-paracaetamol induced alf according to kings college criteria

A

INR> 6.5
Any grade encephalopathy

OR ANY THREE OF THE FOLLOWING:
Non-A, non-B viral hepatitis, drug induced or intermediate aetiology of ALF
Time from jaundice to hepatic encephalopathy >7days
Age<10/>40
INR>3.5
Serum bili >300

19
Q

What are complications of ALF

A

Infection: bacterial or fungal Infections within 3 days

Raised ICP + cerebral oedema:
Risk factors:
Hyperacute>acute>subacute
Serum ammonia>150-200
Clinical correlate of HE grade 3/4
Need for vasopressors or renal replacement therapy
Presence of infection or SIRS

Cardiovascular:
Hyperdynamic circulation

Resp:
Airway compromise leading to resp/metabolic acidosis

Coagulopathy:
Prolonged INR, decreased platelets

Nutrition:
Patients are catabolic

20
Q

How is HE class one classified?

A
21
Q

How is HE class 2 classified

A
22
Q

How is HE class 3 classified as

A
23
Q

How is HE class 4 classified as

A
24
Q

How many grams of protein and calories should a patient eat a day to prevent going to HE grade 3/4

A

1g protein/kg/day
25-30kcal/kg/day

25
Q

How does N-acetyl cysteine help prevent ALF

A

Replenishes glutathione stores and improves systwmic and cerebral haemodynamics

26
Q

How many IVI NAC must be given

A

Loading dose of 150mg/kg in 5% dextrose over 15 min
50mg/kg over 4hrs
100mg/kg over 16hrs

27
Q

True or false: you should wait for paracetamol levels to come back from lab before giving IVI NAC

A

False dont wait

28
Q

What quantity of paracetamol is classified as being hepatotoxic

A

> 10g per day
3-4g/day in setting of chronic alcohol use or malnutrition

29
Q

True or false: acute alcohol use can be protective of Paracetamol hepatotoxicity

A

True

30
Q

What drug should be given immediately when acute herpes simplex hepatitis is suspected

A

IVI acyclovir 10mg/kg 8 hrly immediately

31
Q

True or false: only hsv 2 can cause hepatitis

A

False, both hsv1 and 2 can

32
Q

Where is HSV hepatitis more frequently found

A

Immunocomprimised people and pregnancy

33
Q

What are the clinical symptoms of hsv hepatitis

A

Fever, headache, anorexia with nausea and vomiting, abdominal pain, leukopenia

34
Q

What is the emergency treatment for raised ICP and cerebral oedema

A

IVI 5% dextrose saline drip
IVI 20% mannitol

35
Q

Where is the fulminant presentation of acute hepatitis B more common

A

Co-infection with HIV and HBV

36
Q

What can cause reactivation of HEP B

A

Chemotherapy or immunosuppression

37
Q

What do you give a patient with only HB IgM core Ab positive

A

Lamivudine 150mg
Conversion to tenofovir 300mg daily once clinically stable

38
Q

What are the 3 interacting factors affecting outcome of emergency liver transplants

A

Age
Severity of pre transplant illness
Nature and quality of graft

39
Q

What causes death post transplant

A

Sepsis
Multi organ failurre
Brainstem herniation

40
Q

Fulminant liver failure

A
41
Q

Classification of hepatic encephalopathy

A

Hepatology (5 decks)

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