LIVER FAILUREMOHAMAD HAFIZ BIN MOHAMAD NGARIPMUHAMMAD KHAIRUL ADHA BIN FUAAD

DEFINATION

• Acute liver failure – occur suddenly in healthy liver.

• Chronic liver failure – occur as a result of decompensation of chronic liver disease.

• Fulminant liver failure – clinical syndrome resulting from massive necrosis of liver and leading to severe impairment of liver function.

Hyperacute : encephalopathy within 7 days of onset of jaundice.Acute : within 8-28 days.Subacute : within 5-26 weeks.

Hepatic EncephalopathyNitrogenous waste (ammonia) build up in the circulation and passes to brain (convert to glutamine). Excess glutamine causes osmotic imbalance-cerebral oedema.

• Grade 1 : Altered mood/behaviour, sleep disturbance.• Grade 2 : Increasing drowsiness, confusion, slurred

speech.• Grade 3 : Stupor, incoherence, restlessness, significant

confusion.• Grade 4: Coma.

Rule out other causes – sepsis, trauma, hypoglycemia and seizure activity.

CAUSES• Infection – viral hepatitis (B, C, CMV), yellow fever,

leptospirosis.• Drugs – paracetamol overdose, halothane,

isoniazid.• Toxins – carbon tetrachloride.• Vascular – Budd Chiari syndrome, veno-occlusive

disease.• Other – alcohol, primary biliary cirrhosis,

hemochromatosis, autoimmune hepatitis, Wilson’s disease, fatty liver of pregnancy, alpha 1-antitrypsin deficiency.

Budd-Chiari Syndrome• Hepatic vein obstruction by thrombosis or tumour

causes ischemia and hepatocyte damage.• Presentation – liver failure or insidious cirrhosis,

abdominal pain, hepatomegaly, ascites and increase ALT, portal hypertension occurs in chronic forms.

• Causes – hypercoagulable states ( pregnancy, malignancy, paroxysmal nocturnal haemaglobinuria, polycythaemia rubra vera, thrombophilia), liver tumour, renal tumour, adrenal tumour.

SIGNS

• Jaundice• Hepatic

encephalophaty• Fetor hepaticus

(smells like pear drops)

• Asterixis (flapping tremor)

• Signs of CLD – GynaecomastiaHepatomegalyAscitesLoss of axillary hairHepatorenal syndrome

INVESTIGATIONS• FBC – any infection, bleeding.• Renal profile• LFT• Coagulation profile – prothrombin time, INR, APTT.• CMV and EBV serology.• Chest x-ray• Abdominal ultrasound • Doppler studies of portal vein – in suspected

Budd-Chiari syndrome.• Abdominocentesis - >250/mm3 neutrophils

suggest spontaneous bacterial peritonitis.

MANAGEMENTS• General – -Secure airway with intubation and insert nasogastrict tube to avoid aspiration and remove any blood from stomach.-insert urinary and central venous catheters to assess fluid status – maintain normal body volume.-haemofiltration or heamodialysis if renal failure develops.-avoid sedatives or other drugs with hepatic metabolism.

• Specific – depending on the cause-N acetylcysteine in PCM overdose.-Acyclovir – in viral hepatitis-liver transplant

• Management of complications-cerebral oedema – mannitol.-bleeding – IV vit K.-infection – ceftriaxone, avoid gentamicin (incr. risk of renal failure)-ascites – fluid restriction, low salt diet, diuretics.-encephalopathy – avoid sedatives, decrease protein diet.

THANK YOU…!!!