Liver failure

Question 1

what is liver failure?

Answer 1

decline in hepatic function characterised by;

jaundice (not always)
encephalopthy
coagulopathy (INR > 1.5)

Question 2

Risk factors?

Answer 2

alcohol abuse, 
age >40 years, 
female gender, 
poor nutritional status, 
pregnancy, 
chronic hepatitis B, 
the use of multiple paracetamol preparations - or analgesics for CHRONIC pain.

others;
hepatitis
drug reactions, paracetamol overdose

Question 3

Presenting symptoms?

Answer 3

1. sometimes jaundice
2. Hepatic encephalopathy; ranging from sleep disturbance, personality change to clonus, hyperreflexia, confusion and coma.
3. nausea

less common;
abdo pain (also RUQ tenderness)
nausea, vomiting, malaise
hepatomegaly - if budd chiarri
Asterixis
Fetor hepaticus
Ascites and splenomegaly (in chronic disease or cirrhosis)
Bruising or bleeding
Signs of secondary causes (e.g. bronze skin colour, Kayser-Fleisher rings)
Pyrexia - may indicate infection or liver necrosis

Question 4

What is coagulopathy?

Answer 4

Reduced synthesis of clotting factors

Reduced platelets

Platelet functional abnormalities associated with jaundice or renal failure

Question 5

Why does encephalopathy occur?

Answer 5

Nitrogenous products (e.g. ammonia) is absorbed in the gut and goes via the portal circulation to the liver

A normal liver would be able extract these harmful substances

However, if the liver is failing, these toxic products can go through the liver and reach the brain and exert its effects

Question 6

How is liver failure classified?

Answer 6

It is classified based on the time interval between the onset of jaundice and the development of hepatic encephalopathy

Hyperacute = < 7 days

Acute = 1-4 weeks

Subacute = 1-3 months

Question 7

investigations?

Answer 7

LFTs; high bilirubin, elevated liver enzymes

PT time or INR ; >1.5

U&Es ; elevated urea and creatinine, metabolic derangements

FBC; leukocytosis (if infection), anaemia, thrombocytopenia

ABGs; metabolic acidosis - paractemol overdose espech

Paracetamol level
Pregnancy test - all females - BhCG
viral serology - hepatitis
autoimmune hep markers
serum copper - elevated in wilson's disease

Question 8

Treatment?

Answer 8

1. ITU admission;
   - Resus;
   - Airway intubation/ protection
   - monitor BMs, neurological status etc

consider all for liver transplant

paracetamol overdose - acetylcysteine
autoimmune hepatitis - methylprednisolone
hep b - tenofovir
budd chiari - anticoagulate - Tinz

Question 9

What distribution do we find spider naevi?

Answer 9

In the SVC drainage region