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CDHB

Liver Failure

Where this is suspected commence treatment early.

Clinical and Biochemical Features

• Jaundice.
• Coagulation defects (check prothrombin and Echis ratios).
• Hypoalbuminaemia.
• Encephalopathy (confusion, apraxia, asterixis).
• Ascites.

Causes / Precipitants

• Acute severe hepatic necrosis:
  • Drugs, e.g., paracetamol.
  • Alcohol.
  • Autoimmune - submassive necrosis.
  • Fatty liver of pregnancy.
  • Viral - hepatitis B ± Delta superinfection.
  • Idiopathic.
• Chronic liver disease with acute deterioration:
  • GI haemorrhage.
  • Sepsis (especially Gram -ve).
  • Spontaneous bacterial peritonitis (see ascites), consider cefotaxime 1 g q6h IV or ceftriaxone 2 g IV q24h until culture available.
  • Drugs (especially alcohol, benzodiazepines).
  • Electrolyte disturbance and volume depletion (diuretics, hypokalaemia).
  • Hepatocellular carcinoma. (Check alpha-fetoprotein and/or ultrasound.)

Investigations

• Arterial lactate and ABG in acute liver failure.
• Na, K, urea, creatinine (hepatorenal syndrome).
• Glucose (may require IV glucose infusion).
• Alb, bili, ALP, AST, ALT, GGT.
• CBC + diff, coagulation profile.
• Drug screen (30 mL urine to Toxicology. Blood alcohol, and other drugs as indicated).
• Viral hepatitis testing (assume infectious until result available), smooth muscle/antinuclear antibodies, immunoglobulins.
• Blood cultures.

Treatment

• Acute liver failure, commence N-acetylcysteine infusion.
• Treat any underlying cause (e.g., bleeding varices, sepsis).
• Stop all offending drugs. Avoid benzodiazepines.
• Correct hypokalaemia, hypotension, hypoglycaemia.
• If ascites present, aspirate for diagnostic purposes.
• Correct coagulation defects with vitamin K 10 mg IV slowly; do not give fresh frozen plasma unless actively bleeding (requires Consultant approval).

If encephalopathy suspected

• Avoid all benzodiazepines and sedatives.
• Purge with lactulose 10-30 mL TDS adjusted to produce three loose stools per day. Enemas can also be used.
• Watch for alcohol withdrawal.
• Neomycin or rifaximin may be indicated.
• Consult Gastroenterologist promptly.

Topic Code: 1427