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Flashcards in Acute liver failure Deck (11):
1

Define hyperacute, acute and subacute liver failure

1. Hyperacute: encephalopathy develops within 7d onset of jaundice
2. Acute is within 8-28 days
3. Subacute is when develops 5-26 weeks

Onset of jaundice, coagulopathy INR >1.5 and hepatic encephalopathy in patients with no prior history of liver disease

2

Causes of acute liver failure

1. Infections
Viral hepatitis
Yellow fever
Leptospirosis
2. Drugs
Paracetamol
Halothane
3. Toxins
Poison mushroom
4. Vascular
Budd chiari
Veno-occlusive
5. Other
Alcohol
PBC
Haemachromatosis
AI hepatitis
a1 antitrypsin
Wilson's
Fatty liver of pregnancy
Malignancy
HELLP

3

Risk factors

1. Alcohol
2. Poor nutrition
3. Female
4. >40 yo
5. Pregnancy
6. Chronic hepatitis B
7. Chronic pain and narcotic use
8. Hepatitis C
9. Paracetamol use

4

History and examination

1. Assess exposures: alcohol, drugs, substance, mushrooms
2. Time course from jaundice to encephalopathy
3. Consider acut on chronic
4. Abdominal pain, nausea, vomiting, hepatomegaly
5. Look for evidence of chronic liver disease, encephalopathy (neurological examination)

5

Grades of hepatic encephalopathy

1. Altered mood/behaviour, sleep disturbance
2. Increased drowsiness, confusion, slurred speech
3. Stupor, incoherence, restlessness, confusion
4. Coma

6

Investigations and interpretation

1. LFTs->+bilirubin, +AST/ALT/GGT
2. Prothrombin time/INR->elevated >1.5
3. UEC, glucose->+urea and creatinine, metabolic derangements
4. FBC->leukocytosis, anemia, thrombocytopenia
5. Blood type and screen
6. ABG->metabolic acidosis
7. Lactate->elevated
8. Paracetamol level
9. Urine toxicology screen
10. Factor V leiden-> low
11. Viral hepatitis serologies, EBV, CMV
12. AI hepatitis markers
13/ Serum ceruloplasmin, iron studies
14. Pregnancy test
15. CXR-> ?aspiration pneumonia
16. Abdominal USS->look for hepatic vessel thrombosis, hepatomegaly, splenomegaly, hepatic surface nodularity
17. Urine MCS, blood, ascitic tap

7

Six things to look for on USS

1. Bile duct obstruction
2. Stones
3. Metastasis
4. Echogenecity
5. Focal liver lesion
6. Splenomegaly

8

Most important things to be aware of in acute liver failure

1. Hypoglycemia
2. GI bleeds
3. Encephalopathy

9

Management

1. ABC, elevate head of bed, intubation
2. NGT, NBM
3. Urinary catheter
4. IV access
5. Monitor
Temp, RR, Pulse, BP, urine output, weight daily
Neurology, ICP
Cardiorespiratory
Fluid balance- UEC, ABG
Coagulation
6. Thiamine, folate
7. 10% IV dextrose. Check BG every 4 hours
8. Treat the cause and complications
Bleeding->vit K, PLTs, FFP, pRBCs
Infection->ceftriaxone
Ascites->fluid restriction, low salt, daily weights
Hypoglycemia
Encephalopathy-> avoid sedatives, head tilt, lactulose +/= enemas
Cerebral edema->Hyperventilate, mannitol
8. Nutrition
9. Consider dialysis if renal failure
10. PPI prophylaxis
11. Avoid sedatives, may use lorazepam
12. Infection control
Blood culture
Urine culture
Throat
Sputum
CXR
Cannula and catheter
13. Lisase with transplant team, seniors
14. Admit to ICU

10

Complications of acute liver failure

1. Bleeding
2. Infection
3. Hypoglycemia
4. Encephalopathy
5. Cerebral edema
6. Renal failure
7. Multi-organ failure

11

Poor prognostic factors

1. Grade 3 or 4 encephalopathy
2. Age >40 years
3. Low albumin
4. +INR
5. Drug induced
6. Late onset