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gastroenterology > Liver Failure > Flashcards

Liver Failure Flashcards

1
Q

what is acute liver failure?

A

liver failure occuring in <26 weeks in a patient with a previously healthy liver

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2
Q

what is the onset duration in hyperacute liver failure?

A

<= 7 days

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3
Q

what is the onset duration in acute liver failure?

A

8-21 days

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4
Q

what is the onset duration in subacute liver failure?

A

4-26 weeks

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5
Q

what is chronic liver failure?

A

liver failure on a background of cirrhosis

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6
Q

what are the causes of liver failure?

A
  • infection
  • drugs
  • toxins
  • vascular (budd-chiari syndrome)
  • primary biliary cirrhosis
  • haemochromatosis
  • wilson’s disease
  • autoimmune hepatitis
  • alpha-1 antitrypsin deficiency
  • non-alcoholic fatty liver disease
  • fatty liver of pregnancy
  • malignancy
  • HELLP syndrome
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7
Q

what infections can cause liver failure?

A
  • hepatitis A, B and E
  • yellow fever
  • leptospirosis
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8
Q

what drugs can cause liver failure?

A
  • paracetamol overdose
  • halothane
  • isoniazid
  • MDMA
  • alcohol
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9
Q

what toxins can cause liver failure?

A
  • amanita phalloides mushroom
  • carbon tetrachloride
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10
Q

what are the clinical features of liver failure?

A
  • hepatic encephalopathy
  • abnormal bleeding
  • ascites
  • jaundice
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11
Q

what does the presences of liver failure and chronic liver disease indicate?

A

de-compensation of chronic liver disease

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12
Q

what symptom can be seen in fulminant hepatic failure?

A

raised ICP due to severe cerebral oedema

rapid disease with high mortality rate

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13
Q

what is the pathophysiology of hepatic encephalopathy?

A
  1. ammonia accumulates in the circulation
  2. crosses the blood-brain barrier
  3. detoxified by astrocytes which form glutamine through the amidation of glutamate
  4. excess glutamine disrupts the osmotic balance
  5. astrocytes begin to swell
  6. cerebral oedema
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14
Q

what are the 4 stages of hepatic encephalopathy?

A
  1. altered mood and behaviour, disturbance of sleep pattern, dyspraxia
  2. drowsiness, confusion, slurring of speech and personality change
  3. incoherency, restlessness, asterixis
  4. coma
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15
Q

what is asterixis?

A

hepatic flap

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16
Q

why are liver function tests checked in liver failure?

A
  • albumin - to check liver enzymes
  • bilirubin levels
  • assess synthetic function of the liver
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17
Q

why is INR checked in liver failure?

A
  • look for coagulopathy
  • establish a diagnosis of liver failure
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18
Q

why are FBCs checked in liver failure?

A
  • leucocytosis (possible infective cause)
  • thrombocytopaenia (in chronic liver disease)
  • anaemia
19
Q

why are U&Es checked in liver failure?

A
  • establish baseline renal function
  • look for hepato-renal syndrome
  • look for electrolyte abnormalities (e.g. hypokalaemia can worsen encephalopathy)
20
Q

what specific blood tests are performed to establish a cause?

A
  • paracetamol level
  • hepatitis
  • epstein-barr virus
  • cytomegalovirus serology (viral infection)
  • alpha-1 anti-trypsin
  • caeruloplasmin level (wilson’s disease)
  • iron studies (hereditary haemochromatosis)
  • auto-antibodies (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosisng cholangitis)
21
Q

what test can be done to check for haematochromatosis?

A

iron studies

high ferritin

22
Q

what test can be done to check for alpha-1 antitrypsin deficiency?

A
  • alpha-1 antitrypsin levels
  • spirometry
23
Q

what test can be done to check for wilson’s disease?

A

caeruloplasmin level

24
Q

what complications can arise due to liver failure?

A
  • infection
  • cerebral oedema +/- raised ICP
  • bleeding
  • hypoglycaemia
  • multi-organ failure
25
Q

what are the complications of cirrhosis?

A
  • ascites
  • spontaneous bacterial peritonitis
  • hepatic encephalopathy
  • portal hypertension
  • variceal bleeding
  • hepatorenal syndrome
26
Q

what investigation should be carried out if ascites is present?

A

peritoneal tap should be taken for microscopy and culture to look for spontaneous bacterial peritonitis

27
Q

how is spontaenous bacterial peritonitis confirmed?

A

tap and neutrophil count >250 cells/mm3

28
Q

how do you manage encephalopathy?

A

oral lactulose

helps nitrogenous waste loss through bowels (reducing encephalopathy)

29
Q

how is coagulopathy managed?

A
  • vitamin K
  • fresh frozen plasma can be given if patient is bleeding
30
Q

how is spontaneous bacterial peritonitis managed?

A

broad spectrum antibiotics

ceftriaxone, cefotazime or ciprofloxacin

31
Q

how is renal dysfunction managed?

A
  • may require haemofiltration
  • if requiring fluid resuscitation -> human albumin solution rather than crystalloid fluid
32
Q

what criteria is used to assess liver transplantation?

A

king’s college hospital criteria

33
Q

what is king’s college hospital criteria for liver transplant in paracetamol induced failure?

A

arterial pH <7.3 24hrs AFTER ingestion
OR
* prothrombin time >100s
* AND creatinine >300 umol/L
* AND grade III or IV encephalopathy

34
Q

what is king’s college hospital criteria for liver transplant in non-paracetamol induced failure?

A

prothrombin time >100s
OR any three of:
* drug-induced liver failure
* age <10 or >40
* 1 week from 1st jaundice to encephalopathy
* prothrombin time >50s
* bilirubin >=300 umol/L

35
Q

what is used to treat paracetamol overdose?

A

N-acetyl cysteine

36
Q

what medication is used to reduce the risk of recurrence of overt hepatic encephalopathy?

A

rifaximin

antibiotic that reduces intestinal production and absorption of ammonia

37
Q

how does infection secondary to liver failure present?

A
  • fever and raised WBC absent in 30% of patients
38
Q

how does budd-chiari present?

A
  • acute or sub-acute liver failure
  • abdominal pain
  • ascites
  • hepatomegaly
39
Q

what is hereditary haemochromatosis?

A

genetic condition of increased intestinal iron absorption that results in :
* joint pains (2nd and 3rd MCP joints)
* erectile dysfunction
* slate-grey skin pigmentation
* cirrhosis
* dilated cardiomyopathy
* osteoporosis

40
Q

what investigation should be carried out in suspected hereditary haemochromatosis?

A

ferritin level and transferrin saturation
* ferritin >1 mg/L
* transferrin saturation >45%

41
Q

what is the treatment for hereditary haemochromatosis?

A

regular venesection

42
Q

what INR level constitutes coagulopathy?

A

INR of >1.5

43
Q

what is budd-chiari syndrome?

A

obstruction of the hepatic veins (often by thrombosis)

44
Q

how is budd-chiari diagnosed?

A

doppler ultrasound of the hepatic veins

gastroenterology (20 decks)

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