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Liver Failure

Acute liver failure is the onset of liver failure (hepatic encephalopthy and coagulopathy) in those w/o a hx of liver disease, whereas Chronic liver failure is with a hx of liver disease.


Causes:

  • Paracetamol overdose

  • Alcohol - More seen in those with pre-existing liver disease

  • Infections - Hep B and C, Yellow fever

  • Toxins - Certain mushrooms

  • Vascular - Budd-Chiari syndrome

  • Other - Fatty liver disease, Primary biliary cholangitis, Haemochromatosis, Wilson’s disease, malignancy


Presentation:

  • Hepatic encephalopathy - Here, ammonia builds up and astrocytes in the brain clear it by changing it to glutamine. This excess glutamine affects the osmotic balance, leading to cerebral oedema.

  • Coagulopathy (abnormal bleeding)

  • Jaundice

  • Ascites

  • Fetor hepaticus (breath smells like pear drops)

  • Liver flap

  • Signs of CLD


Investigations:

  • Bloods - FBC, U&E, LFT, Albumin, INR, Glucose, Paracetamol levels, Hep screen, a1-antitrypsin

  • Ascitic tap if appropriate, checking for SBP

  • Blood and urine culture

  • Abdo USS


N.B. PT/INR is the best test to demonstrate the synthetic function of the liver.


The SAAG (Serum Ascites Albumin Gradient) can be measured in the ascitic fluid. This gives an idea on the cause (similar to a pleural tap):

  • < 1.1 = Ascites is due to portal hypertension e.g. cirrhosis, CHF, portal vein thrombosis

  • > 1.1 = Ascites is NOT due to portal hypertension e.g. peritoneal cancer, malignancy, nephrotic syndrome


N.B. In portal hypertension, the raised hydrostatic pressure forces water out into the peritoneal cavity whilst albumin remains in the vessels, therefore resulting in a higher difference in the albumin concentration between the serum and ascitic fluid.


Complications:

The most common complication here is Infection, which tends to present atypically, with no fever or raised WCC. Other complications include:

  • Cerebral Oedema ± raised ICP

  • Bleeding

  • Hypoglycaemia


Management:

  • Treat the underlying cause

  • Monitor obs closely, including blood glucose

  • For hepatic encephalopathy

    • Lactulose to help gut excretion of ammonia

    • IV mannitol to help reduce cerebral oedema

  • For coagulopathy - Vit K and FFP

  • For SBP - Abx

  • Liver transplantation may be needed



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