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L19 hepatic failure

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  • 1. HepaticFailureLecture 19
  • 2. • The most severe clinical consenquences ofliver disease is hepatic failure . It generallydevelops as the end point of progressivedamage to the liver,• either insidious destruction of hepatocytes or• repititive discrete waves of parenchymaldamage.
  • 3. • Less commonly, hepatic failure is the resultof sudden and massive destruction of hepatictissue.• Whatever the sequence, 80% to 90% ofhepatic function must be lost before hepaticfailure ensues.
  • 4. DefinitionLiver failure is the inability of the liver toperform its normal synthetic and metabolicfunction as part of normal physiology.Two forms are recognized, acute and chronic.
  • 5. • A course expending as long as 3 months iscalled subacute failure.
  • 6. • The alterations that cause liver failure fall intothree categories:• 1. Acute liver failure with massive hepaticnecrosis• 2. Chronic liver disease• 3. Hepatic dysfunction without covertnecrosis
  • 7. Acute Hepatic Failure• Acute hepatic failure is defined as "the rapiddevelopment of hepatocellular dysfunction,specifically coagulopathy and mental statuschanges (encephalopathy) in a patientwithout known prior liver disease".
  • 8. Acute liver failure with massive hepatic necrosis• Caused by drugs or fulminant viral hepatitis• ALF denotes clinical hepatic insufficiency thatprogresses from onset of symptoms to hepaticencephalopathy within 2 to 3 weeks.
  • 9. Morphology• The histologic correlate of acute liver failure ismassive hepatic necrosis.
  • 10. ChroniC hepatiC failure• Chronic hepatic failure usually occurs in thecontext of cirrhosis.
  • 11. Chronic liver disease• This is the most common route to hepaticfailure and is the end point of relentless chronicliver damage ending in cirrhosis.
  • 12. 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 causesthe body to absorb and store too much iron)• Malnutrition
  • 13. Hepatic dysfunction without overtnecrosis• Hepatocytes may be viable but unable toperform normal metabolic function,
  • 14. Causes• Tetracycline toxicity, and• Reye syndrome.
  • 15. Types ABC• Type A (=acute) describes hepatic encephalopathyassociated with acute liver failure, typicallyassociated with cerebral oedema• Type B (=bypass) is caused by portal-systemicshunting without associated intrinsic liver disease• Type C (=cirrhosis) occurs in patients with cirrhosis -this type is subdivided in episodic, persistent andminimal encephalopathy
  • 16. Clinical features• Jaundice and cholestasis• Hypoalbuminemia• Hypoglycemia• Palmar erythema• Spider angioma• Hypogonadism• Gynecomastia• Weight loss• Muscle wasting
  • 17. Early symptoms• Nausea• Loss of appetite• Fatigue• Diarrhea
  • 18. Serious Symptoms• Jaundice• Bleeding easily• Swollen abdomen• Mental disorientation or confusion (known ashepatic encephalopathy)• Sleepiness• Coma
  • 19. Complications of Hepatic Failure• Coagulopathy• Hepatic encephalopathy• Hepatorenal syndrome
  • 20. Hepatic encephalopathy• Hepatic encephalopathy (also known asportosystemic encephalopathy) is theoccurrence of confusion,altered level of consciousness, and coma as aresult of liver failure. In the advanced stages itis called hepatic coma or coma hepaticum. Itmay ultimately lead to death.
  • 21. Signs & symptoms• Forgetfulness,• mild confusion,• irritability and• coma.
  • 22. West Haven Criteria• Grade 1 - Trivial lack of awareness; euphoria oranxiety; shortened attention span; impairedperformance of addition or subtraction• Grade 2 - Lethargy or apathy; minimaldisorientation for time or place; subtlepersonality change; inappropriate behaviour• Grade 3 - Somnolence to semistupor, butresponsive to verbal stimuli; confusion; grossdisorientation• Grade 4 - Coma (unresponsive to verbal ornoxious stimuli)
  • 23. Other signs & symptoms• jaundice,• ascites,• peripheral oedema.• tendon reflexes exaggerated,• Babinskis sign positive• foetor hepaticus
  • 24. 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%).
  • 25. Hepatorenal syndrome• The development of renal failure withoutprimary abnormalities of the kidneysthemselves.• Kidney function promptly improves if hepaticfailure is reversed.
  • 26. Etiology• Splanchnic vasodilation &• systemic vasoconstriction,leading to severe reduction of renal blood flow.
  • 27. Clinical features• Drop in urine output, associated with risingblood urea nitrogen and creatinine values.
  • 28. • The renal failure may hasten death in thepatient with acute fulminant or advancedchronic hepatic disease.• Alternatively, borderline renal insufficiencymay persist for weeks to months.

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