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home - Liver - Liver Failure - Acute Liver Failure Written by Dr Sebastian Zeki
Knowledge


Assesses the severity of liver dysfunction and its prognostic
significance following haemorrhage

Knows importance of correcting hypovolaemia preventing
complications of GI bleeding and deterioration of liver function and
stopping bleeding

Knows the potential use of blood & clotting factors the role of
antibiotics the use of vasoconstrictors therapeutic endoscopy the
indication for transjugular intra-hepatic portosystemic shunt (TIPS) or
surgical shunt surgery

Aware of the specific complications of bleeding in cirrhotic patients –
including hepatic encephalopathy need for airway protection
nutrition identification of alcohol withdrawal

Skills
Shows proficiency in endoscopy – including emergency endoscopic
techniques of variceal band ligation endoscopic sclerotherapy
injection of cyanoacrylate glues for gastric varices

Can place safely and manage a Sengstaken tube in refractory
variceal bleeding

Can prevent and treat complications including hepatorenal failure
ascites spontaneous bacterial peritonitis and hepatic encephalopathy

Behaviours
Appreciates criteria for referral to specialist centre when appropriate –
such as with bleeding gastric or ectopic varices or consideration of
TIPS

Appreciates need to treat patients using a multi–disciplinary approach
Shows understanding of an empathic approach which may involve


Also....

Knowledge
Knows risks and prognosis of recurrent variceal bleeding in cirrhotic
patients

Aware of role of secondary prophylaxis with either non–selective ?-
blockers endoscopic ligation or both

Skills
Can select suitable endoscopic therapy and perform the appropriate
procedure competently

Behaviours
Appreciates the potential role of other specialists e g interventional
radiologists and nurse specialists

Also...

Knowledge


Understands the mechanisms of biliary metabolism the various
abnormalities that lead to hyperbilirubinaemia and knows and
recognises the causes of the various forms of jaundice

Skills
Selects and interprets appropriate investigations and formulate
management plans

Behaviours
Approaches patients presenting with jaundice in a logical and
methodical manner

Also...
Knowledge


Can define the different types (I and II) of hepatorenal
syndrome(HRS)

Knows the differential diagnosis of different types of renal
failure/impairment in liver disease

Understands the major and minor criteria in diagnosis of HRS and be
able to differentiate between HRS and acute kidney injury

Appreciates the prognostic significance of renal impairment in
patients with chronic liver disease

Knows the options for management and treatment of HRS the role of
colloids and vasoconstrictors as well as renal supportive treatment by
dialysis

Skills
Uses and interprets result of sometimes complex investigations
appropriately

Behaviours
Can judge when to involve other specialists especially nephrologists
radiologists and intensivists

Also...

Knowledge


Understands the pathogenesis of hepatic encephalopathy (HE)
Knows the differential diagnosis of HE including the existence of risk
factors for its causation including metabolic disorders and intracranial
structural disorders (such as subdural haematomas)

Knows factors that may precipitate HE including bleeding electrolyte
disturbance drugs or other organ failure

Knows the various treatment options appropriate for grade of severity

Skills
Can grade the mental state (Glasgow coma score and West Haven
Criteria)

Shows ability to differentiate between acute and acute on chronic liver
injury

Can identify the patient at risk of raised intracranial pressure and
cerebral oedema

Selects and use investigations appropriately and determine timing of
airway protection

Behaviours
Appreciates the role of other specialists and interacts in a
professional manner with intensivists neurologists
neurophysiologists radiologists and other specialists

Makes referral where appropriate to specialist centre for liver
transplantation

Also...

Knowledge


Understands the causes of acute hepatitis including viral druginduced alcohol-induced and auto-immune liver disease

Knows the appropriate plan of investigation and management of
specific diseases including the role of serological investigations and
liver biopsy

Skills
Takes an accurate history from patients with acute liver disease and
performs detailed clinical examination

Utilises investigation in a structured manner
Behaviours
Considers all therapeutic modalities and preparedness to refer to
specialist centre where diagnosis remains in doubt or appropriate
management cannot be performed

Also...

Knowledge
Assessment
Methods GMP
Recognises and knows how to diagnose acute and chronic drug
induced liver injury and dysfunction
SCE 1,2
Aware of methods of diagnosis, role of liver biopsy and therapy
including role of steroids in treatment in selected cases
SCE, CbD 1
Skills
Understands the role of both prescription and recreational drugs and
the aetiology of a wide variety of liver disease and dysfunction often
requiring prompt intervention or involvement of specialist services
SCE, CbD 1,2,3
Has awareness of the range of iatrogenic liver dysfunction SCE, CbD 1,2,3
Behaviours
Able to interact with specialist pharmacy services. Can use yellow
card reporting system of potential adverse effects of drugs.

Also....

Knowledge


Understands the causes and pathophysiology of acute liver failure
Can plan appropriate investigation evaluate prognosis and construct
a detailed management plan

Identifies those potentially suitable for emergency liver transplantation
Skills
Develops ability to make accurate evaluation of patients with liver
failure at the stage of initial presentation

Can deliver management plan appropriately evaluate changes in
patient’s condition and react accordingly

Utilises the range of medical interventions necessary to support
critically ill patients

Behaviours
Demonstrates ability to identify patients at risk of developing acute
liver failure and understand the criteria for referral to specialist centres

Works collaboratively with nurses and all ITU staff as well as
colleagues in other clinical disciplines to deliver the highest standard
of clinical care

Communicates effectively and relates with empathy to family and
close friends of patients

Acute Liver Failure

Non Paracetamol ALF Referral Criteria: - Hepatic encephalopathy. - INR more than 1.5. - Hepatorenal failure. - Acute Wilson's disease. Written by Dr Sebastian Zeki Determining Aetiologies and Specific Therapies Management Definition: It is defined as a coagulopathy and encephalopathy without cirrhosis + illness of < 26wks.Patients with Wilson disease, vertically-acquired HBV, or autoimmune hepatitis may be included in spite of the possibility of cirrhosis if their disease has only been recognized for < 26 weeks. Time course definitions:Encephalopathy within 8 wks of symptom onset with prev healthy liverEncephalopathy within 2 weeks of developing jaundice, even if prev liver dysfunctionSubfulminant if > above but < 6 mCerebral oedema common in fulminant disease and rare in subfulminant disease.Renal failure and PHTN are more frequently observed in patients with subfulminant hepatic failure. Fulminant hepatic failureIt is defined as a rapid severe acute liver injury with impaired synthetic function and encephalopathy with previously normal/ well compensated liver. PT over 100 seconds irrespective of coma grade ORAny 3 of the following, irrespective of coma grade:– Drug toxicity, indeterminate cause of ALF– Age under 10 years or over 40 years‡– Jaundice to coma interval < 7 days‡– PT over 50 seconds (INR over 3.5)– Serum bilirubin over 300 mol/L (17.5 mg/dL) Assessment of prognosis Paracetamol: Not significant liver damage if INR normal 48 hours after an overdose (ignore raised ALT if INR normal). G Hypoglycaemia Give continuous glucose infusions. Need electrolyte replacement repeatedly R Hepatorenal syndrome Maintain adequate intravascular volume. Dialysis support continuous rather than intermittent Other measures as per ‘Hypotension’ E Hepatic encephalopathy/cerebral oedema A Haemorrhage T Hypotension -Pulmonary artery catheterization -Volume replacement -Pressor support (dopamine, epinephrine, norepinephrine) as needed to maintain adequate mean arterial pressure -NAC, prostacyclin: effectiveness unknown -Vasopressin: not helpful in ALF; potentially harmful. Co Coagulopathy Correct if severe or bleeding (need platelets >10 or > 50-70 for procedures FFP if bleeding and INR >1.5 Recombinant activated factor VII sometimes useful N Nutrition If enteral feedings are contraindicated (e.g., severe pancreatitis), use parenteral nutrition, although infection risk Enteral and parenteral nutrition may reduce the risk of GI bleeding due to stress ulceration in critically ill patients. G Gastritis Gastrointestinal Bleeding Prophylactic PPI or H2 blockers needed Hemodynamics/Renal Failure S Sepsis Do periodic surveillance cultures for bacteria and fungus Prophylactic antibiotics and anti-fungals is considered but have not been shown to improve overall outcomes Paracetamol HepatotoxicityMushroom PoisoningUsually Amanita phalloidesSuspect if severe GI symptoms within hours to days of ingestionTx: Activated charcoal/ penicillin G + silymarin/ early transplant referralDrug Induced HepatotoxicityUsually within 6m after drug initiation. Viral HepatitisHepatitis A – 4% Hep C doesnt cause ALFHepatitis E is a significant cause of liver failure in countries where it is endemic, worse in pregnant women.Hepatitis B – 8% of ALF Herpes virus (rare)Inc risk in immunosuppressed/pregnant (usually 3rd trimester) - also reported in healthy individuals. Skin lesions in 50%.Treat with acyclovir.Wilson diseaseALF + Wilson’s- place on transplant listNo penicillamine in acute settingAutoimmune hepatitisMay have unrecognized preexisting chronic disease and yet still be considered as having ALFTx: Steroids and put on transplant listAcute Fatty Liver of Pregnancy/HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelets) Syndrome-Consultation with obstetrical services and expeditious delivery are recommended.Acute Ischemic InjurySupportive onlyBudd-Chiari SyndromeIf have ALF- indication for liver transplantation Diagnosis and Initial EvaluationOccasionally jaundiced/ RUQ pain.-Can get large liver in viral hepatitis/ malignant infiltration, congestive heart failure, or acute Budd-Chiari syndrome.-A liver biopsy indicated when autoimmune hepatitis, metastatic liver disease, lymphoma, or herpes simplex hepatitis suspected. Acute Liver FailureGeneral ConsiderationsNo role of steroidsProstacyclin and other prostaglandins in trialsNAC may be useful but not in all ALF causes Indications for referral include - PT more than hours after presentation (eg 60 seconds after 48 hours) - PT increasing on 4th day - Creatinine >150 - ABG pH < 7.30 - Encephalopathy or hypoglycaemia King’s College Criteria:

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