Liver Failure. Nora Aziz. Bones, Brains & Blood Vessels

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1 Liver Failure Nora Aziz Bones, Brains & Blood Vessels

2 Severe deterioration in liver function Looses ability to regenerate/repair decompensated Liver extensively damaged before it fails Equal male:female ratio Geographical variant of aetiology

3 Liver failure Fulminant liver failure Subacute Fulminant Hepatic Failure Chronic decompensated hepatic failure Within 8 weeks onset of disease 8 to 26 weeks More than 6 months

4 Viral Hepatitis B Adenovirus EBV CMV Metabolic Diseases Alpha 1 anti-trypsin deficiency Fructose intolerance Galactosaemia Tyrosinaemia Acute fatty liver of pregnancy Reye s syndrome Ischaemia Veno occlusive disease Budd Chiari (acute hepatic vein thrombosis) Alcoholic Neoplasms Hepatocellular ca Metastatic Ca Viral Haemorrhagic fevers Drugs Paracetamol overdose Augmentin

5 Early Nausea loss of appetite Diarrhoea fatigue Late

6 Jaundice haemorrhagic diathesis Malaena haematemesis Ascites Liver encephalopathy

7 Acute Reverse cause Symptom relief

8 Chronic Salvage functioning liver Transplant 75% survival rate at 1 year 90% mortality without transplant Screening/genetic counselling

9 Bleeding Hepatic Encephalopathy & Cerebral Oedema Renal Failure Respiratory failure Sepsis

10 Due to decreased synthesis of coagulation factors Common site GI tract Oesophageal varices Retroperitoneal haemorrhage Prevent and treat stress ulcers H2 blocker infusion, sucralfate, PPI

11 LIKELY DUE TO increased production of ammonia from nitrogenous substances within the gut lumen ( serum ammonia >200ug/dL) astrocyte metabolic disturbance lactulose+neomycin Reduces ammonia production

12 Grade Characteristic Spontaneous recovery I II MENTAL CHANGES Euphoria, anxiety, reduced attention span, lack of awareness Lethargy, disorientation, personality changes, inappropriate behaviour 65-70% III Stupor, but responsive to stimuli, gross disorientation, confusion 45-50% IV coma <20%

13 75-80 % occurs in Grd IV hepatic Encephalopathy Osmotic derangement in astrocytes Altered cerebral blood flow Metabolic derangement Cushings triad Bradycardia Hypertensive Irregular breathing

14 Hypoglycaemia >40% of patients Results frm depletion of hepatic glycogen stores+impaired gluconeogenesis May add glucose infusion to keep glucose >:3.6 mmol Hypokalaemia Diuretic therapy Increased uptake of K into cells frm sympathetic tone

15 Increased risk Commonly UTI and RTI Spontaeneous bacterial Peritonitis Opportunistic infection and pneumonia Absent fever and sputum, worsening encephalopathy/ renal function

16 dehydration, hepatorenal syndrome, or acute tubular necrosis > common in acetaphitamine induced liver failure Volume contraction Decreased intake Transudative loss? GI blood loss Requires fluid resus : colloids

17 Pulmonary oedema &/ infection occurs in 30 % May require ventilation Use of PEEP has to be carefully balanced to avoid worsening of cerebral oedema

18 reverse Acetaminophen Dose related >10 mg/day (4mg/day in alcoholics) Detection: high serum levels 3500IU/L reversed with Activated Charcoal within 1-3 hrs n-acetylcysteine

19 aetiology Hepatic encephalopathy Age Good prognosis in pt aged10 to 40

20 Low (>50% transplant free survival) Hepatitis A Hepatitis B Acetaminophen Shock liver Pregnancy related High ( <25% transplant free survival)

21 Should be considered early if course of deterioration expected Kings College Hospital criteria Non acetaphitamine PT >100 or Aged <10 or >40 Non A, non B bepatitis, drug reaction, Onset of jaundice >7days before encephalopathy

22 Wide range of complication Presents late Important to determine aetiology for prognosis and correct management Fatal Educate against preventable causes Early treatment

23 AASLD guideline: The management of acute liver failure Published in Hepatology 2005; 41:1179. Copyright 2005 American Association for the Study of Liver Diseases Julie Polson and William M. Lee Fulminant hepatic failure: Definition; etiology; and prognostic indicators AND Overview of the treatment of fulminant hepatic failure Eric Goldberg and Sanjiv Chopra, UpToDate Kumar And Clarke, Clinical Medicine, Third Edition Saunder s Pocket Essentials Oxford Pocket Handbook of Clinical Medicine 2002 Talley and O Connor, Clinical Examination, Fourth Edition 2001

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