Liver Failure

Question 1

Define liver failure

Answer 1

Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy

From onset of jaundice to development of hepatic encephalopathy:
• Hyperacute <7 days
• Acute 8-28 days
• Subacute 29 days – 12 weeks

Acute-on-chronic: acute decompensation in patients with chronic liver disease

Question 2

What are the causes/risk factors of liver failure?

Answer 2

Causes
• Paracetamol overdose (50%)
• Idiosyncratic drug reactions e.g. isoniazid
• Hepatitis A, B, D, E
• Autoimmune hepatitis
• Budd-Chiari syndrome
• Malignancy
• Haemochromatosis
• Amanita phalloides poisoning
• Wilson’s disease
• PBC
• PSC

Risk factors
• Alcohol abuse
• Poor nutritional status (depletion of glutathione stores)
• Pregnancy (hepatitis E)
• Chronic hepatitis B

Question 3

What are the symptoms of liver failure?

Answer 3

• Jaundice
• Abdominal pain
• Nausea & vomiting
• Malaise

Symptoms of hepatic encephalopathy
• Sleep reversal -> Lethargy ->
Somnolence -> Stupor
• Reduced awareness and attention span
-> Poor memory and confusion

Question 4

What are the signs of liver failure?

Answer 4

• Hepatomegaly
• Abdominal or RUQ tenderness

Signs of hepatic encephalopathy
• Asterixis
• Hyperreflexia
• Nystagmus
• Clonus
• Rigidity

Signs of cerebral oedema
• Hypertonia
• Decerbrate posturing
• Loss of pupillary reflexes

Question 5

What investigations are carried out for liver failure?

Answer 5

• liver function tests - hyperbilirubinaemia, elevated liver enzymes
• prothrombin time/INR - elevated INR (>1.5)
• basic metabolic panel - elevated urea and creatinine, metabolic derangements
• FBC - leukocytosis, anaemia, thrombocytopenia
• blood type and screen
• arterial blood gas - metabolic acidosis
• arterial blood lactate - elevated
• paracetamol level
• urine toxicology screen
• factor V level - low (<20% to 30% of normal)
• viral hepatitis serologies
• autoimmune hepatitis markers
• serum ceruloplasmin -low (<50 mg/L [<5 mg/dL]) in Wilson’s disease
• pregnancy test
• chest x-ray
• abdominal ultrasound with Doppler - hepatic vessel thrombosis, hepatomegaly, splenomegaly, hepatic surface nodularity

Question 6

What is the management for liver failure?

Answer 6

• Treat the underlying cause if possible: N-Acetyl Cysteine or Glutathione for Paracetamol Overdose.
• Monitor basic bedside observations.
• Airway intubation
• NG Tube to prevent aspiration
• Urinary catheter –to monitor for renal function and detect Hepatorenal syndrome.
• IV Fluids
• Correct electrolyte imbalances
• Prevent sedatives and other drugs metabolized by the liver.
• Nutritional Support
• Treat Complications:
• Cerebral Oedema: Nurse the patient at 30 0C. Hyperventilate and 20% IV mannitol.
• Encephalopathy: Lactulose, phosphate enemas and Rifaximin (This reduces the number of gut bacteria that form ammonia).
• Antibiotic and Antifungal prophylaxis –Ceftriaxone not gentamicin to prevent AKI.
• Hypoglycemia: IV Glucose
• Bleeding: IV Vitamin K, FFP and/or platelet infusion. Blood transfusion, if indicated.
• Renal Failure: Terlipressin for HRS. May need Haemofiltration and nutritional support.
• Surgical: ALF: King’s College Criteria

Question 7

What are the complications of liver failure?

Answer 7

• Coagulopathy
• Ascites
• SBP
• Encephalopathy
• HRS
• Hypoglycaemia
• Electrolyte Disturbances
• Cerebral Oedema and raised ICP