Liver failure
Upper GI haemorrhage
LIVER FAILURE
Aetiology
Assessement
A
Deterioration of chronic liver impairment

Alcohol

GIT haemorrhage

Infection – bacterial peritonitis, viral hepatitis

Drugs – diuretics, hypnotics, sedatives, narcotics

Metabolic – hypokalaemia, hypoglycaemia

Other – constipation, surgery
B
Acute causes

Drugs – paracetamol, idiosyncratic (phenytoin amiodarone,
isoniazid, valproate, sulphonamides)

Viral hapatitis – A, B, C, D, E

Toxins – amanita phalloides, carbon tetrachloride

Vascular events – ischaemia, veno-occlusive disease, heatstroke,
malignancy

Other – Wilson’s (<50); acute fatty liver of pregnancy (3 rd trimester)
Reye’s syndrome.
A
Aims to determine the precipitant as well as assess the current state
B
ABC’s i.e. CVS and respiratory
C
Neurological

Asterixis – characteristic but not specific

Hyper reflexia

Grade of hepatic encephalopathy
Grade 1: Mildly drowsy, impaired concentration and
psychomotor function
Grade 2: Confused but able to answer questions
Grade 3: Very drowsy – reponds to simple commands
Grade 4: Unrousable
4a Responsive to pain
4b Unresponsive
D
GIT



D
Renal


E
Urinary catheter to monitor fluid status
Oliguric renal failure develops in 50%
General

Investigations
Jaundice
PR blood loss
Bacterial peritonitis
Look for infection
LFT’s – elevated. May return to near normal in end stage
Urea, Cr, Na+, K+, PO4, Mg – hyponatraemia, hypokalaemia
Glucose – hypoglycaemia
Coagulation – prolonged PT (>4 seconds)
FBC – infection, low platelets
ABG – lactic acidosis is bad prognostic indicator
Paracetamol level
Blood culture
Urine culture
Ascites for MCS if present
CXR
+ viral hepatitis screen
)
+ plasma caeruloplasmin )
+ toxicology
)
Management
in acute failure
ABC’s
Maintain glucose >3.5mmol/L

10% dextrose 1L 12 hourly and monitor glucose 1 – 4 hourly and if decreased
consciousness
Fluid and electrolyte balance

Maintain K+ >3.5mmolL with supplements

Avoid saline, use 5%, 10% dextrose or colloids

Treat ascites with spironolactone, frusemide and albumin

Low salt diet
Correct coagulation

Vitamin K 10mg IV daily

Folic acid 10mg orally daily

Platelets if <20 – 50,000
Decrease nitrogen load

Stop dietary protein

Lactulose 30ml 3 hourly until diarrhoea then 30ml BD

Mag sulphate enema if GI bleeding
Decrease risk of stress ulceration

Ranitadine 150mg BD orally or 50mg 8 hourly or sucralfate 1g QID orally
Treat infection
Treat cause – NAC if paracetamol
Avoid elevating ICP

Head up 100

Consider ICP monitoring
Disposition
Gastroenterology
Consult with DCCM + liver transplant unit
UPPER GI HAEMORRHAGE
RESUSCITATION / A,
B, Cs




Oxygen
16g IV cannulae x 2
FBC, INR,U&E, Cr, LFTs, Group & Hold / Crossmatch
Crystalloid, colloid, blood and clotting factors PRN
ASSESSMENT

Assess as High risk – any one of the following risk factors
Age > 60
Systolic BP < 100
Hb < 90 g / l
Varices or cirrhosis
Co-existing disease (CVS, renal, hepatic)
Confusion
High risk findings at endoscopy may religate the patient to high risk from low
risk
stigmata of recent haemorrhage, Dieulafoy’s lesion, varices, carcinoma








Or as low risk in the absence of these

ECG

CXR
FURTHER
MANAGEMENT
Dependant on risk assessment
High Risk












Continue resuscitation and monitoring
Omeprazole 20mg orally
Octreotide 50 micrograms then 50 micrograms per hour if varices
Endoscopy – discuss with gastroenterology registrar. Perform in resuscitation
room if unstable. Alternatives are DCCM or theatre.
Only haemodynamically stable patients are to be transferred to the Endoscopy
Unit.
Surgery – surgical registrar should see the patient. Surgery is considered if
Exsanguinating bleed
Excessive transfusion requirement
> 55 or co-morbidity ; > 4 units / 24 hours
<55; 6 – 8 units / 24 hours
Re-bleed (or 2 re-bleeds and low risk)
Carcinoma
Low Risk




Admit to medical unit
Can eat and drink until 6 hours prior to endoscopy
Endoscopy on next routine list
Surgical registrar is to be made aware of the patient