Table Of Contents
Hepatic Failure
Hepatic failure is characterized by the development of coagulopathy (INR > 1.5) and encephalopathy. It may be sudden or chronic and often occurs in patients with cirrhosis (chronic hepatic failure.
Definition of terms
| Term | Definition |
|---|---|
| Acute hepatic failure | Liver failure occuring suddenly in a previously healthy liver. Hyperacute onset < 7 days, acute onset 8 – 21 days, subacute onset 4 – 26 weeks |
| Chronic hepatic failure | Liver failure occuring on a background of cirrhosis |
| Fulminant hepatic failure | Results from massive necrosis of liver cells causing severe impairment of liver function |
Causes of hepatic failure
| Category | Causes |
|---|---|
| Infection | Viral infection (HBV, HCV, CMV), yellow fever, leptospirosis |
| Drugs | Paracetamol overdose, halothane, isoniazid |
| Toxins | Amanita phalloides, carbon tetrchloride |
| Vascular | Veno-occlusive disease, Budd-chiari syndrome |
| Other causes | Alcohol, fatty liver disease, primary biliary cholangitis, primary sclerosing cholangitis, hemachromatosis, autoimmune hepatitis, a1-antitrypsin deficiency, wilson’s disease, fatty liver of pregnancy, malignancy |
- Signs and symptoms of hepatic failure
- Jaundice
- Hepatic encephalopathy
- Fetor hepaticus
- Asterixis
- Constructional apraxia
- Signs of chronic liver disease (suggestive of acute-on-chronic hepatic failure)
- Investigations
- Complete blood count: rule out infection or gastrointestinal bleeding
- Liver function tests
- Coagulation panel
- Prolonged PT and INR > 1.5
- Hepatitis serology
- Ferritin
- a-1 antitrypsin
- Ceruloplasmin
- Autoantibodies
- Blood culture
- Urine culture
- Ascitic tap for MCS: rule out SBP (neutrophils > 250/mm3)
- Chest X-ray
- Abdominal ultrasound
- Doppler of the portal vein and hepativ vein
- EEG
- Treatment
- ICU admission
- Protect airway and intubate if indicated
- Elevate head of bed
- NG tube to avoid aspiration
- Urinary catheter and central venous catheter for fluid status
- Monitor vitals, urine output and daily weighing
- Repeat CBC, UECs, LFT and INR daily
- Treat cerebral oedema: with IV mannitol
- Treat ascites
- Treat bleeding with Vitamin K and blood products +/- endoscopy
- Treat hypoglycaemia
- Treat encephalopathy
- Drugs to avoid in hepatic failure
- Drugs that constipate (increase the risk of encephalopathy)
- Oral hypoglycaemics
- Saline-containing IVs
- Hepatotoxic drugs
- Paracetamol
- Methotrexate
- Isoniazid
- Azathioprine
- Phenothiazines
- Oestrogen
- 6-MP
- Salicylates
- Tetracycline
- Mitomycin
- Note that the effects of warfarin are enhanced
- Factors for poor prognosis
- Grade III-IV encephalopathy
- 40 years old
- Albumin < 30 g/L
- Raised INR
- Drug-inudced hepatic failure
- Late-onset hepatic failure
