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Write about Liver Failure here. • Acute-On-Chronic Hepatic Failure Causes: • Infections • viral hepatitis, yellow fever, leptospirosis • Drugs • paracetamol overdose, halothane, isoniazid • Toxins • Amanita phalloides mushrooms, carbon tetrachloride • Vascular • Budd-Chiari Syndrome, veno-occlusive disease • Other • Primary Biliary Cirrhosis, haematosis, autoimmune hepatitis, alpha1-antitrypsin deficiency, Wilson's Disease, fatty liver of pregnancy, malignancy Clinical Features: • Hepatic Encephalopathy is graded as follows: • Grade I Altered mood or behaviour • Grade II Increasing drowsiness, confusion, slurred speech • Grade III Stupor, incoherence, restlessness, significant confusion • Grade IV Coma • Other features • Jaundice, fetor hepaticus (pear drops), asterixis, constructional apraxia (ask to draw a five-pointed star) • Signs of chronic liver disease suggest acute-on-chronic hepatic failure Investigations: • Bloods (FBC, U&E, LFT(bilirubin, AST and ALT up), clotting (PT/INR up), glucose, paracetamol level, hepatitis serology, ferritin, alpha1-antitrypsin, caeruloplasmin • Micro Cultures - blood, urine, ascites - ascitic neutrophils > 250/mm3 = spontaneous bacterial peritonitis • Radiology CXR, abdo USS, Doppler of portal vein (& hepatic - in suspected Budd-Chiari syndrome) • Neurophysiological EEG may show high-voltage slow waveforms Management: Beware sepsis, hypoglycaemia, and encephalopathy • Nurse with a 20 degree head-up tilt in ITU • NG tube • Give 10% dextrose IV 1L/12hr to avoid hypoglycaemia • 50 ml 50% dextrose IV if BM <3.5 (check every 1-4hr) • If malnourished -> dietary help. Thiamine and folate supplements as needed • Haemofiltration of haemodialysis, if renal failure develops Prognosis: • Poor prognostic factors: «Grade III or IV encephalopathy «Age > 40 years «Albumin <30 g/L «Drug-induced liver failure «Late-onset hepatic failure worse than fulminant failure «65% survival post-transplantation |
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