Liver Failure

Write about Liver Failure here.


Acute Hepatic Failure

Acute-On-Chronic Hepatic Failure

Fulminant Hepatic Failure

Late-onset Hepatic Failure


Causes:

• Infections

• viral hepatitis, yellow fever, leptospirosis

• Drugs

• paracetamol overdose, halothane, isoniazid

• Toxins

Amanita phalloides mushrooms, carbon tetrachloride

• Vascular

Budd-Chiari Syndrome, veno-occlusive disease

• Other

Primary Biliary Cirrhosis, haematosis, autoimmune hepatitis, alpha1-antitrypsin deficiency, Wilson's Disease, fatty liver of pregnancy, malignancy


Clinical Features:

• Hepatic Encephalopathy is graded as follows:

Grade I Altered mood or behaviour

• Grade II Increasing drowsiness, confusion, slurred speech

• Grade III Stupor, incoherence, restlessness, significant confusion

• Grade IV Coma

Other features

• Jaundice, fetor hepaticus (pear drops), asterixis, constructional apraxia (ask to draw a five-pointed star)

• Signs of chronic liver disease suggest acute-on-chronic hepatic failure


Investigations:

Bloods (FBC, U&E, LFT(bilirubin, AST and ALT up), clotting (PT/INR up), glucose, paracetamol level, hepatitis serology, ferritin, alpha1-antitrypsin, caeruloplasmin

Micro Cultures - blood, urine, ascites - ascitic neutrophils > 250/mm3 = spontaneous bacterial peritonitis

Radiology CXR, abdo USS, Doppler of portal vein (& hepatic - in suspected Budd-Chiari syndrome)

Neurophysiological EEG may show high-voltage slow waveforms


Management: Beware sepsis, hypoglycaemia, and encephalopathy

• Nurse with a 20 degree head-up tilt in ITU

• NG tube

• Give 10% dextrose IV 1L/12hr to avoid hypoglycaemia

• 50 ml 50% dextrose IV if BM <3.5 (check every 1-4hr)

• If malnourished -> dietary help.  Thiamine and folate supplements as needed

• Haemofiltration of haemodialysis, if renal failure develops


Prognosis:

Poor prognostic factors:

«Grade III or IV encephalopathy

«Age > 40 years

«Albumin <30 g/L

«Drug-induced liver failure

«Late-onset hepatic failure worse than fulminant failure

«65% survival post-transplantation