1. Hepatic
Failure
Lecture 19

2. • 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.

3. • 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.

4. Definition
Liver 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.

5. • A course expending as long as 3 months is
called subacute failure.

6. • 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

7. 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".

10. 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.

11. Morphology
• The histologic correlate of acute liver failure is
massive hepatic necrosis.

12. ChroniC hepatiC failure
• Chronic hepatic failure usually occurs in the
context of cirrhosis.

13. 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.

14. 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

15. Hepatic dysfunction without overt
necrosis
• Hepatocytes may be viable but unable to
perform normal metabolic function,

16. Causes
• Tetracycline toxicity, and
• Reye syndrome.

17. 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

18. Clinical features
• Jaundice and cholestasis
• Hypoalbuminemia
• Hypoglycemia
• Palmar erythema
• Spider angioma
• Hypogonadism
• Gynecomastia
• Weight loss
• Muscle wasting

19. Early symptoms
• Nausea
• Loss of appetite
• Fatigue
• Diarrhea

20. Serious Symptoms
• Jaundice
• Bleeding easily
• Swollen abdomen
• Mental disorientation or confusion (known as
hepatic encephalopathy)
• Sleepiness
• Coma

21. Complications of Hepatic Failure
• Coagulopathy
• Hepatic encephalopathy
• Hepatorenal syndrome

22. 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.

23. Signs & symptoms
• Forgetfulness,
• mild confusion,
• irritability and
• coma.

24. 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)

25. Other signs & symptoms
• jaundice,
• ascites,
• peripheral oedema.
• tendon reflexes exaggerated,
• Babinski's sign positive
• foetor hepaticus

26. 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%).

27. Hepatorenal syndrome
• The development of renal failure without
primary abnormalities of the kidneys
themselves.
• Kidney function promptly improves if hepatic
failure is reversed.

28. Etiology
• Splanchnic vasodilation &
• systemic vasoconstriction,
leading to severe reduction of renal blood flow.

29. Clinical features
• Drop in urine output, associated with rising
blood urea nitrogen and creatinine values.

30. • 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.