l19 hepatic failure
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Hepatic Failure
Lecture 19
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• The most severe clinical consenquences of liver disease is hepatic failure . It generally develops as the end point of progressive damage to the liver,
• either insidious destruction of hepatocytes or • repititive discrete waves of parenchymal
damage.
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• Less commonly, hepatic failure is the result of sudden and massive destruction of hepatic tissue.
• Whatever the sequence, 80% to 90% of hepatic function must be lost before hepatic failure ensues.
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DefinitionLiver failure is the inability of the liver to
perform its normal synthetic and metabolic function as part of normal physiology.
Two forms are recognized, acute and chronic.
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• A course expending as long as 3 months is called subacute failure.
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• The alterations that cause liver failure fall into three categories:
• 1. Acute liver failure with massive hepatic necrosis
• 2. Chronic liver disease• 3. Hepatic dysfunction without covert
necrosis
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Acute Hepatic Failure• Acute hepatic failure is defined as "the rapid
development of hepatocellular dysfunction, specifically coagulopathy and mental status changes (encephalopathy) in a patient without known prior liver disease".
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Acute liver failure with massive hepatic necrosis
• Caused by drugs or fulminant viral hepatitis
• ALF denotes clinical hepatic insufficiency that progresses from onset of symptoms to hepatic encephalopathy within 2 to 3 weeks.
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Morphology• The histologic correlate of acute liver failure is
massive hepatic necrosis.
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Chronic hepatic failure
• Chronic hepatic failure usually occurs in the
context of cirrhosis.
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Chronic liver disease• This is the most common route to hepatic
failure and is the end point of relentless chronic liver damage ending in cirrhosis.
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Causes of CLF• The most common causes of chronic liver failure
(where the liver fails over months to years) include:• Hepatitis B• Hepatitis C• Long term alcohol consumption• Cirrhosis• Hemochromatosis (an inherited disorder that causes
the body to absorb and store too much iron)• Malnutrition
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Hepatic dysfunction without overt necrosis
• Hepatocytes may be viable but unable to perform normal metabolic function,
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Causes
• Tetracycline toxicity, and • Reye syndrome.
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Types ABC• Type A (=acute) describes hepatic encephalopathy
associated with acute liver failure, typically associated with cerebral oedema
• Type B (=bypass) is caused by portal-systemic shunting without associated intrinsic liver disease
• Type C (=cirrhosis) occurs in patients with cirrhosis - this type is subdivided in episodic, persistent and minimal encephalopathy
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Clinical features• Jaundice and cholestasis• Hypoalbuminemia• Hypoglycemia• Palmar erythema• Spider angioma• Hypogonadism• Gynecomastia• Weight loss• Muscle wasting
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Early symptoms
• Nausea• Loss of appetite• Fatigue• Diarrhea
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Serious Symptoms
• Jaundice• Bleeding easily• Swollen abdomen• Mental disorientation or confusion (known as
hepatic encephalopathy)• Sleepiness• Coma
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Complications of Hepatic Failure
• Coagulopathy• Hepatic encephalopathy• Hepatorenal syndrome
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Hepatic encephalopathy• Hepatic encephalopathy (also known as
portosystemic encephalopathy) is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure. In the advanced stages it is called hepatic coma or coma hepaticum. It may ultimately lead to death.
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Signs & symptoms• Forgetfulness, • mild confusion,• irritability and • coma.
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West Haven Criteria
• Grade 1 - Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction
• Grade 2 - Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour
• Grade 3 - Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation
• Grade 4 - Coma (unresponsive to verbal or noxious stimuli)
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Other signs & symptoms• jaundice, • ascites, • peripheral oedema. • tendon reflexes exaggerated, • Babinski's sign positive• foetor hepaticus
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Causes• Liver failure, • large amount of protein consumption,• GIT bleeding, • renal failure, • constipation, • Hyponatremia,• hypokalemia,• alkalosis, • hypoxia,• dehydration, • sedatives, narcotics, alcohol intoxication,• surgery,
• unknown (2o-3o%).
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Hepatorenal syndrome
• The development of renal failure without primary abnormalities of the kidneys themselves.
• Kidney function promptly improves if hepatic failure is reversed.
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Etiology• Splanchnic vasodilation & • systemic vasoconstriction, leading to severe reduction of renal blood flow.
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Clinical features • Drop in urine output, associated with rising
blood urea nitrogen and creatinine values.
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• The renal failure may hasten death in the patient with acute fulminant or advanced chronic hepatic disease.
• Alternatively, borderline renal insufficiency may persist for weeks to months.
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