1. Mostafa AbdelMaksoud 890.

2. Mostafa Mazen 891.

3. Mostafa Mohamed Diaa 894.

4. Mostafa Mohamed Rasslan 895.

5. Mostafa Mohamed Abdelkader 897.

6. Mustapha Mansour Ahmed 898.

7. Motaz Helmy 900.

8. Manar Sobhy AlNakeeb 901.

9. Manar Sabry Mohamed 902.

10. Manar Adly Ibrahim 903.

11. Manar 904.

By: Mostafa AbdelMaksoud 890

Liver failureThe most severe clinical consequences of liver disease is hepatic failure . It generally develops as the end point of progressive damage to the liver.

80% to 90% of hepatic function must be lost before hepatic failure ensues.

Types

Acute Subacute Chronic

Chronic liver failureInability of the liver to perform its normal synthetic and metabolic function as part of normal physiology.

Chronic liver failure is a deterioration of liver function that occurs over a long period of time, generally months to years

It usually occurs in the context of cirrhosis

Chronic liver failure is the most common form of liver failure

Causes:Cirrhosis

Development of scar tissue that replaces normal parenchyma. This scar tissue blocks the portal flow of blood through the organ therefore disturbing normal function.

Damage to the hepatic parenchyma leads to activation of the stellate cell, which increases fibrosis and obstructs blood flow in the circulation.

It secretes TGF-β1, which leads to a fibrotic response and proliferation of connective tissue. Furthermore, it secretes TIMP 1 and 2, naturally occurring inhibitors of matrix metalloproteinases, which prevents them from breaking down fibrotic material in the extracellular matrix.

ViralHepatitis BHepatitis C

Excessive alcohol intakeChronic consumption of alcohol results in the secretion of pro-inflammatory cytokines (TNF-alpha, Interleukin 6 and Interleukin 8). These factors cause inflammation, apoptosis and eventually fibrosis of liver cells.

HemochromatosisDisorder related to deficiency of the iron regulatory hormone hepcidin. HHC is an autosomal recessive genetic disease in which increased intestinal absorption of iron causes accumulation in tissues, especially the liver, which may lead to organ damage.

Autoimmune hepatitisAnomalous presentation of human leukocyte antigen (HLA) class II on the surface of hepatocytes causes a cell-mediated immune response against the liver

By: 1- Mostafa Mazen 891.

2- Mostafa Mohamed Diaa 894.

General

Fatigue , drowsiness and weight loss

Fever & septicemia

Jaundice

Ascites

Hepatic encephalopathy

Skin Plamar erythrima

Spider angioma

Caput medusa

Pegmentations

Pruritis

Haematological and Endocrine Anemia

Bleeding tendency

Gynecomatia

Feminine distribution of hair

Sign associated with aetiology

Parotidomegally

Dupuytern’s contracture (Viking disease)

Peripheral neuropathy

Signs of right heart failure

Kayser-Fleisher rings

Other Leukonychia (White nails)

Hepato-renal syndrome

Hepato-pulmonary syndrome

Increase incidence of infection

By: Mostafa Mohamed Rasslan 895.

Diagnosis :Clinical picture :

Nausea

Loss of appetite

FatigueDiarrhea

Weight loss

The initial symptoms:

As liver failure progresses, the symptoms

become more serious.Jaundice

hyperestrogenemia

Ascites

Hepatic encephalopathy

Fever and septicemia

Bleeding form esophageal

varices

Fetor hepaticus

fasting hypoglycemia

Lab investigation:

CBC with platelets.

Prothrombin time.

Serum bilirubin.

Serum albumin.

ALT – AST

ALP

Radiological investigation

Ultrasound

MRI

Ultrasonography (US)

EEG

MR spectroscopy (MRS)

CSF.

Treatment:

The only curative treatment is liver transplantation

ICU to maintain BP, pulse, mental status with nasogastric tube

Glucose to treat hypoglycemia

Antibiotics

reference http://www.webmd.com/digestive-disorders/digestive-

diseases-liver-failure#2 http://www.webmd.com/a-to-z-guides/sepsis-septicemia-

blood-infection http://www.medicinenet.com/liver_disease/page2.htm http://www.rightdiagnosis.com/symptoms/fetor_hepaticus

/common.htm http://www.webmd.com/digestive-disorders/alkaline-

phosphatase-alp-test http://emedicine.medscape.com/article/366426-overview http://radiopaedia.org/articles/cirrhosis http://radiopaedia.org/articles/mr-spectroscopy-1

By: Mostafa Mohamed Abdelkader895.

Complications Chronic injury to the liver, regardless of the cause,

results in a wounding response that leads to fibrosis, and ultimately scarring and replacement of normal liver architecture by regenerative nodules.

Portal Hypertension

Ascites

an accumulation of fluid in the peritoneal cavity.

Hypersplenism

reduction in the number of circulating blood cells affecting granulocytes, erythrocytes or platelets.

Lower oesophageal varices and rectal varices

Synthetic Dysfunction Hypoalbuminaemia.

Coagulopathy.

in which the blood’s ability to clot (coagulate) is impaired.

Other complications :-

Hepatopulmonary Syndrome

a syndrome of shortness of breath and hypoxemiacaused by vasodilation in the lungs of patients with liver disease.

Hepatorenal Syndrome

a life-threatening medical condition that consists of rapid deterioration in kidney function.

Encephalopathy

a spectrum of reversible

neuropsychiatric abnormalities.

Hepatocellular Carcinoma.

Prevention :-

1. Get vaccinated against hepatitis A and B.

2. Do not use multiple medications or illicit drugs unwisely.

3. If you have any member of the family of friend who is sick, avoid contact with blood or bodily fluids.

4. Eat healthy exercise and keep your weight down.

5. Do not drink alcohol.

6. Screening for Hepatocellular Cancer.

By: Mustapha Mansour Ahmed 898.

Definition: The clinical manifestation of sudden and severe

hepatic injury with the onset of coma and coagulopathy up to within 6 months. However, onset is usually Within 1-6 weeks from the onset of any signs of illness.

Etiology:

Acetaminophen-Related Liver:- The most common cause of ALF in the US.

- Caused by overdose & toxicity.

- Acetaminophen-Alcohol poisoning.

Drug-induced injuries:- 10% of drug-induced liver injuries progress to acute liver failure.

- anti-infectives, anticonvulsants, and anti-inflammatory drugs most commonly implicated.

Viral Hepatitis: - Cases of viral hepatitis that develop hepatic failure represent a small fraction of all cases (1%). - Mainly HBV with HAV.- HEV maybe present, but less frequently.- HBV maybe due to new acute infection or acute on top of chronic.

Other causes:- hyperthermic injury from heat shock.- specific toxic insults such as Amanita(mushroom) Poisoning.- immunological insults from autoimmune hepatitis.- ischemic injury as a result of systemic hypotension in sepsis or cardiac failure.

By: 1- Motaz Helmy 900.

2- Manar Sobhy AlNakeeb 901.

SYPMTOMS OF ACUTE LIVER FAILURE • Yellowing of your skin and eyeballs (jaundice)

• Pain in your upper right abdomen

• Abdominal swelling

• Nausea

• Vomiting

• A general sense of feeling unwell (malaise)

• Disorientation or confusion

• Sleepiness

Signs of acute liver failure

Encephalopathy

Right upper quadrant tendernessCerebral edema

JaundiceAscites

Change in liver span

Hyperdynamiccirculation

A) Definition and Etiology:

By: Manar Sabry Mohamed 902

Prothrombin Time/INR

Blood Chemistry

Sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate, AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin, Creatinine, urea, Glucose

Arterial blood gas

Arterial lactate

Full blood count

Blood type and screen

Ammonia

HIV status

Amylase and lipase

Paracetamol (acetaminophen) level Toxicology screen Viral hepatitis serologies

Anti-HAV IgM, HBSAg, anti-HBc IgM, anti-HEV, anti-HCV CMVEBVVZ/HZ

Ceruloplasmin level Pregnancy test Autoimmune markers- ANA, ASMA, Immunoglobulin levels Doppler US- ischaemic vs thrombosis liver biopsy

Paracetamol N-Acetylcysteine

HAV, HBV declining in importance Lamivudine

HEV now a common cause

HSV and other Herpes group viruses Aciclovir, Ganciclovir

Allopathic and non-allopathic Withdrawal

Alcoholic hepatitis Steroids, Pentoxifylline

Autoimmune hepatitis Corticosteroids

Wilson’s disease Chelation therapy

Ischaemic hepatitis Restoration of hepatic

circulation

Budd-Chiari syndrome Hepatic

decompression

GPH, Acute fatty liver Delivery

D) Prevention & Complications:

By: 1- Manar Adly Ibrahim 903.

2- Manar 904.

(cerebral edema).:Excessive fluid causes pressure to build in your brain, which can displace brain tissue outside of the space it normally occupies (herniation). Cerebral edema can also deprive your brain of oxygen.

bleeding disorders: A failing liver isn't able to produce sufficient amounts of clotting factors, which help blood to clot. People with acute liver failure often develop bleeding from the gastrointestinal tract. Bleeding may be difficult to control.

Infections:

People with acute liver failure are at an increased risk of developing a variety of infections, particularly in the blood and in the respiratory and urinary tracts.

Kidney failure:

Kidney failure often occurs following liver failure, especially in cases of acetaminophen overdose, which damages both your liver and your kidneys.

Coma – Mental confusion:

difficulty concentrating and disorientation (hepatic encephalopathy) can progress to coma if liver function does not return.

For encephalopathyAgents which reduce ammonia

•Ornithine aspartate may aid conversion of ammonia into glutamine in muscle,

•Lactulose

cerebral edema) :brief hyperventilation can be used, particularly when herniation is suspected.

- Head-up position

- Early intubation

Coagulopathy

- Platelet transfusions

- H2blockers may help prevent GI bleeding

Infection is treated with antibacterial and/or antifungal drugs; treatment is started

as soon as patients show any sign of infection

renal failure :

- Volume control of acetaminophen

- Early use of renal replacement therapy

The best way to prevent liver failure is to limit your risk of developing cirrhosis or hepatitis

This can be done by following :

- dosage directions on all prescription, herbal and over-the-counter medications (including acetaminophen)

- avoiding risky behavior- exercising caution when using any type of chemicals and living a healthy

lifestyle.

So to prevent acute liver failure ::

Follow instructions on medications : the pateint must take the recommended dosage, and don't take more than that.

Alcohol amount if necessary must be limited, no more than one drink a day for women of all ages and men older than 65 and no more than two drinks a day for younger men.

Avoid smoking

• Vaccination against HBV

• Avoid contact with other people's blood and body fluids.

• Don't eat wild mushrooms

• Take care with aerosol sprays , insecticides, fungicides, paint and other toxic chemicals

• healthy weight as : Obesity can cause a condition called nonalcoholic fatty liver disease, which may include fatty liver, hepatitis and cirrhosis.