Types of Liver Failure
Liver failure can be divided into three types
- Fulminant hepatic failure
- Chronic liver failure
- Acute on chronic liver failure
Fulminating Hepatic Failure
- It occurs as a result of massive necrosis of liver cells or any other severe impairment of liver function.
- The cardinal feature is a severe and progressive encephalopathy occurring within 8wks of first symptoms of illness.
Liver Failure Etiology
- Viral hepatitis.
- Drug induced – isoniazid, rifampicin, non-steroidal anti-inflammatory drugs, anti-convulsion.
- Metabolic – Wilson’s disease, toxemia of pregnancy (hypertension during pregnancy and its complications).
- Ischemic hepatitis.
- Jaundice is invariable but in fulminating liver failure may be occasionally preceded by coma. Factors responsible are hemolysis (destruction of cells), decreased bilirubin excretion and impaired hepatic conjugation.
- Bleeding tendency- usually gastric and duodenal erosions.
Stages of Hepatic encephalopathy
- Prodromal- irritability, impaired memory, lack of concentration may be seen.
- Impending coma- clear cut mental confusion, slurred speech. Patient sleeps most of the time but can be aroused. Flapping tremor of outstretched hands and characteristic sweet smell of fetor hepaticus in breath.
- Coma- pupil’s dilated, rapid and deep respiration and decerebrate posturing.
- Due to sustained rise in intra-cranial pressure.
Renal failure and electrolyte disturbance are common.
Management of Fulminating hepatic failure
- Elimination or control of precipitating factors like gastrointestinal bleed, large protein uptake, severe constipation, urinary and chest infection, electrolyte imbalance is to be done.
- Reduction of nitrogenous material in bowel
- Protein free diet- fruit juices, coconut water, soups, glucose through naso-gastric tube.
- Daily bowel wash with 2-4gm neomycin added.
- Lactulose 15ml syrup thrice a day lactulose or enema.
Treatment of metabolic abnormalities like hypoglycemia with intravenous glucose, hypokalemia with potassium chloride, hypocalcemia with intravenous gluconate and hyponatremia with fluid restriction is done. Treatment of cerebral edema with mannitol is done.
Chronic Liver Failure
- Chronic liver failure or chronic hepatocellular failure is characterized by nay combination of jaundice, ascites (fluid collection in abdominal cavity) and encephalopathy with persisting signs of hepatic de-compensation in a patient with underlying chronic liver disease usually cirrhosis.
- In addition, there are abnormalities of other body systems including renal impairment, defective hemostasis; progressive mal-nutrition and increased susceptibility to the infections.
- A patient shows signs of long standing chronic liver disease such as palmer erythema and spider naevi with liver and spleen enlargement.
Acute on chronic liver failure
- Acute episodes of de-compensation may occur when an additional injury further compromises an already impaired liver function.
Precipitating factors for acute on chronic failure are
1. Increased nitrogen load as in
- Gastrointestinal bleeding
- Large uptake of protein
- Severe constipation
- Sub-acute bacterial peritonitis
- Urinary infection
- Chest infection
3. Electrolyte imbalance due to
- Diuretic medicines