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liver failure Flashcards

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1
Q

What is jaundice?

A

Elevated levels of bilirubin in blood plasma

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2
Q

What blood concentration of bilirubin is: Normal

A

17μmol/L

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3
Q

What blood concentration of bilirubin is: Yellow sclera

A

> 30μmol/L

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4
Q

What blood concentration of bilirubin is: Yellow skin

A

> 34μmol/L

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5
Q

What is cholestasis and its relevance in jaundice?

A

Slow or cessation of bile flow. Is a cause of jaundice

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6
Q

What are some Pre-hepatic causes of jaundice?

A

Haemolytic anaemia, toxins, ineffective erythropoesis, large haematoma resorption

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7
Q

What is a pre-hepatic jaundice typically associated with?

A

Increased production of bilirubin

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8
Q

What are some intrahepatic causes of jaundice?

A

Gilberts syndrome (reduced BR uptake), Crigler-Najar syndrome (reduced BR conjugation), Dubin-Johnson and Rotor syndrome (reduced BR secretion), Sepsis, TPN, drugs, acute & chronic liver failure

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9
Q

What are some post-hepatic causes of jaundice?

A

Gallstones, tumours, obstructions and inflammation of ducts

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10
Q

What is the simple pathophysiology of liver failure?

A

Rate of hepatocyte generation < rate of hepatocyte death (combination of apoptosis and necrosis)

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11
Q

What are the classifications of acute liver failure?

A

Fulminant and Sub-Fulminant

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12
Q

What is Fulminant liver failure?

A

rapid onset of liver failure (<8wks), reduced synthetic function and encephalopathy with previously normal liver function

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13
Q

Sub-fulminant liver failure?

A

< 6 month onset

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14
Q

What is chronic liver failure?

A

Onset over years, marked cirrhosis

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15
Q

What is the most common toxin to cause acute LF in the western world?

A

Paracetamol overdose (behind amanita phalloides, bacillus cereus)

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16
Q

What is the most common cause of acute liver failure in the eastern world?

A

Inflammation (due to Hep B or E)

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17
Q

What process exclusive to females can induce acute liver failure?

A

Acute fatty liver of pregnancy (AFLP), HELLP syndrome (haemolysis, elevated liver enzy. Low platelets), hepatic infarction, Budd-Chiari syndrome and Hep E

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18
Q

Which common drug interactions can cause acute liver failure?

A

Amoxicillin+clavulanic acid, trimethoprim+sulphamethoxazole, rifampicin+isoniaizid

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19
Q

What single drugs can cause acute liver failure?

A

Isoniazid, NSAID’s, valproate

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20
Q

Name two metabolic diseases which can cause acute liver failure?

A

Wilsons disease, Reye’s syndrome

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21
Q

Name some vascular diseases which can cause acute liver failure?

A

Ischaemic hepatitis, post-OLTx, hepatic artery thrombosis, post arrest, VOD

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22
Q

Name all the broad causes of chronic liver failure (I ‘AD CINA - say it in a cockney accent)

A

Inflammation, Alcohol abuse, Drug side effects, Cardiovascular effects, Inherited disease, NASH, Autoimmunity

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23
Q

Explain the process of cirrhosis

A

Noxious factor -> necrosis -> enzyme leakage -> cytokines activate kupffner and granulocytes -> fibroblast proliferation and microfibroblast activation -> fibrosis -> cirrhosis -> inflammation -> fibrosis etc

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24
Q

Consequence of LF on: Production of clotting factors

A

coagulopathy and bleeding

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25
Consequence of LF on: Protein synthesis
ascites
26
Consequence of LF on: Detoxification
encephalopathy and cerebral oedema
27
Consequence of LF on:Glycogen storage
hypoglycaemia
28
Consequence of LF on: Immunological function, globin production
susceptibility to infection
29
Consequence of LF on: Homeostasis
circulatory collapse, renal failure, MOF
30
Reduction in what protein leads to ascites?
Albumin
31
What does reduced albumin result in?
2° hyperaldosteronism, hypokalaemia and alkalosis
32
What clotting factors are produced in the liver?
All but Von Willebrand and VIII
33
What is the difference between chronic and acute liver failure?
Onset of failure and causes, cirrhosis
34
How does cholestasis aggravate bleeding tendencies?
Reduced bile salts, reduced micelles and absorption of Vit K resulting in poor γ-carboxylation of vit K dependent clotting factors (prothrombin, VII, IX, X)
35
What is one of the biggest signs of liver failure?
Pruritus - scratch marks, pain in upper right quadrant, abdominal swelling, cholesterol deposits around eyes, nausea, sleepiness and confusion. Gynaecomastia in males. Spider naevi (more than 5)
36
What are spider naevi?
Cluster of visible vessels under the skin with a central spot - if pressed they refill from the centre
37
What is clubbing?
Curved flat nails
38
How is gynaecomastia caused by liver failure?
Increased oestrogen production and reduced clearance results in a rise in oestrogen levels above testosterone
39
How is excessive bleeding possible?
Thrombocytopenia, reduced clotting factors and varices (thin walled collateral vessels taking more blood than normal)
40
How is cholestasis caused by liver failure?
``` Canalicular dilation cell membrane stiffness deformed brush border biliary transporter issues increased tight junction permeability decreased mitochondrial ATP synthesis ```
41
What are the consequences of cholestasis on the body?
Jaundice. Pruritis. Cholesterol deposition (esp around eyes) malabsorption and steatorrhoea, cholangitis
42
How can portal hypertension be caused by liver failure?
Scar tissue causes reduced hepatic venous outflow causing pressure buildup
43
What is exudative/hepatic encephalopathy?
Exudation of fluid over BBB which is carrying toxins causes encephalopathy
44
What are the signs of encephalopathy?
Memory loss, confusion, tiredness, loss of consciousness
45
How is exudative/hepatic encephalopathy caused?
Loss of albumin causes ascites, which causes bacteria in large bowel to increase liberation of ammonia (very toxic to brain) and/or toxins bypass liver (non-functional) so aren't extracted and/or false transmitters from aromatic AAs increase
46
What are the prehepatic causes of portal hypertension?
Portal vein thrombosis
47
What are the intrahepatic causes of portal hypertension?
can be presinusoidal, sinusoidal and post sinusoidal
48
Presinusoidal causes of PH
chronic hepatitis, PBC, granulomas (TB etc)
49
Sinusoidal causes of PH
acute hepatitis, ALCOHOL, FATTY LIVER, amyloidosis, toxins
50
post sinusoidal causes of PH
venous occlusive disease, Budd-Chiari
51
What are the posthepatic causes of PH?
Right heart failure, constrictive pericarditis
52
What are the consequences of PH on the body?
Malabsorption, splenomegaly, thrombocytopenia and anaemia, vasodilation (hypotension), encephalopathy, varices
53
Describe a few causes of hepatic encephalopathy
Hyperammonaemia, hypokalaemia, toxins, false transmitters
54
Where are the most common varices found? What veins are involved?
Oesophagus, azygos vein and oesophageal tributaries of left gastric vein
55
How is the severity of liver failure scored?
Child-Pugh scoring using blood tests and examinations
56
What is the life expectancy of someone with a Child-Pugh score of 5-6
15-20 years
57
What is the treatment for someone with a Child-Pugh score of 7-9
Transplant candidates! (but 30% perioperative mortality)
58
What is the life expectancy of someone with a Child-Pugh score of 10-15
1-3 months :( not recommended transplant as 82% risk of POM
59
What sort of treatment is given to those with liver failure?
Supportive treatments unless transplant is possible
60
What is the most common cause of death during liver failure?
Bacterial or fungal infections
61
How do you support encephalopathy?
Reduce protein intake, phosphate enemas, lactulose (empty the bowels), avoid any sedation
62
How do you support hypoglycaemia and hypocalcaemia?
Infuse 10-50% dextrose, 10ml 10% calcium gluconate
63
How do you support renal and respiratory failure?
Haemofiltration, ventilation
64
What would you give to help hypotension?
Albumin and vasoconstrictors
65
What would you give to prevent infection after liver failure?
Frequent cultures and antibiotics
66
What would you give to prevent bleeds after liver failure?
Vitamin K, Fresh Frozen Plasma, platelets
67
For what is liver transplant most commonly done?
Chronic liver failure (cirrhotic liver)
68
What type of cancer would you likely treat with a liver transplant?
Hepatocellular cancer
69
What type of cancer would you not want to use a liver transplant for?
Any metastatic cancers - immunosuppression after transplant is a BAD IDEA
70
How does portal hypertension increase varices?
increased vasodilation release to relieve PH (vip, prostacyclins, glucagon) decreases blood pressure. cardiac output increases to stabilise o2, leading to HYPERperfusion of abdo - varices increase
71
what are varices?
thin walled collateral vessels take on too much load and enlarge due to PH or obstruction, combined w thrombocytopenia and decreased clotting factors, increases bleeds of veins
72
what is icterus?
fancy word for jaundice
73
how does secondary hyperaldosteronism cause encephalopathy?
produces hypokalaemia, leads to intracellular acidosis, ammonia formation in proximal tubules of kidney leading to systemic alkalosis which causes the encephalopathy
74
how does liver failure induce secondary hyperaldosteronism?
as PH induces vasodilation, BP decreases which is countered by increased renin-angiotensin-aldosterone system, increasing aldosterone with little negative feedback as the BP doesn't then increase

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