My Clinical Notes
- Acute liver failure – occurring in a previously healthy liver
- Acute on chronic liver – decompensation of chronic liver disease
- Fulminant hepatic failure – clinical syndrome resulting in massive necrosis of hepatocytes
Causes
- Infection
- Viral hepatitis
- Yellow fever
- Leptospirosis
- Drugs
- Paracetamol OD
- Halothane
- Isoniazid
- Toxins
- Carbon tetrachloride
- Vascular
- Budd-Chiari syndrome
- Veno-occlusive disease
- Other causes
- Alcohol hepatitis
- Primary biliary cirrhosis
- Haemochromatosis
- Wilson’s disease
- Autoimmune hepatitis
- ?1-antitrypsin deficiency
- Fatty liver of pregnancy
- Malignancy
Signs
- Jaundice
- Hepatic encephalopathy
- Fetor hepaticus
- Asterixis
- Constructional apraxia (ask patient to draw a 5 pointed star)
- Look for signs of chronic liver disease e.g.
- Leuconychia
- Clubbing
- Palmer erythema
- Hyperdynamic circulation
- Dupuytren’s contracture
- Spider naevi
- Xanthelasmata
- Gynaecomastia
- Atrophic testes
- Loss of body hair
- Parotid enlargement
- Hepatomegaly
- Small liver late in disease
Tests
- Bloods
- FBC (infection? GI bleed)
- U&Es
- LFTs
- Clotting
- Glucose
- Paracetamol levels
- CMV & EBV serology
- Ferritin
- ?1-antitrypsin
- Caeruloplasmin
- Autoantobodies
- Radiology
- CXR
- Abdominal ultrasound
Management
- Things you should be aware of – sepsis, hypoglycaemia and encephalopathy
- Nurse at 20 degrees head up tilt in ITU
- Insert urinary and central catheters to monitor fluid balance
- Monitor obs hourly, also monitor weight
- Check FBC, U&Es, LFTs and INR daily
- Give 10% dextrose IV 1L/12hr to avoid hypoglycaemia (monitor BMs every 4hr)
- Treat cause e.g. paracetamol OD
- Give thiamine and folate supplements
- If renal failure develops haemofiltrate or haemodialyse
- Avoid sedatives and other drugs with hepatic metabolism. Treat seizures with lorazepam
- Consider PPI as prophylaxis against stress ulceration (omeprazole)
- Liaise with nearest transplant centre
Treat complications
- Bleeding
- Vit K, platelets, FFP and blood as needed
- Infection
- Ceftriaxone until cultures come back. Avoid gentamycin
- Ascites
- Fluid restrict, low salt diet, monitor weight daily, diuretics
- Encephalopathy
- Avoid sedatives, nurse at 20 degrees. Give lactulose and regular enemas to reduce the number of nitrogen producing bacteria in the gut
- Cerebral oedema
- 20% mannitol and hyperventilate
Hepatic encephalopathy
- As the liver fails nitrogenous waste (as ammonia) builds up in the circulation and passes to the brain where astrocytes clear it by processes that involve the conversion of glutamate to glutamine
- The excess glutamine causes osmotic imbalance and a shift of fluid into these cells. This results in cerebral oedema
Hepatorenal syndrome
- Splanchnic arterial vasodilation results in decreased circulatory volume, intense renal vasoconstriction and reduced GFR
- There is normal renal histology
- Renal vasoconstriction is worsened by activation of the renin-angiotensin-aldosterone axis and production of ADH
- Ensure other diagnoses of renal impairment have been excluded
- There are 2 types of hepatorenal syndrome;
- HRS1
- Rapidly progressive deterioration in circulatory and renal function (median survival <2wk)
- HRS2
- More steady deterioration (median survival 6mth)
- HRS1
- Treatment is IV albumin and arterial vasoconstrictors e.g. terlipressin
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