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Cirrhotic patients may have stable liver function for long periods of time, and an acute insult in the presence of advanced fibrosis and decreased functional reserve may lead to the development of hepatic decompensation. Patients with Acute on Chronic liver failure have short-term mortality of 50%-90%

About

• Chronic hepatocellular failure occurs there is decompensation
• Chronic liver disease +/- precipitant
• Patients present with ascites or encephalopathy
• No usually reversible unless treatable precipitant

Aetiology of chronic liver disease

• Alcoholic liver disease
• Autoimmune liver disease
• Non-alcoholic steatohepatitis
• Chronic Viral hepatitis B/C , Less so CMV, EBV
• Primary Biliary cirrhosis
• Wilson disease
• Haemochromatosis
• Primary Sclerosing cholangitis
• Alpha 1 antitrypsin deficiency
• Cystic fibrosis
• Drugs: amiodarone/Methotrexate/Nitrofurantoin
• Type IV Glycogen storage disease
• Sarcoidosis
• Budd Chiari syndrome
• Cardiac disease and right heart failure
• Idiopathic

Clinical

• Look for jaundice, ascites, cachexia, variceal bleeding
• Assess for encephalopathy, spider naevi, pruritis
• Look for bruising, splenomegaly, rashes or arthritis.
• Encephalopathy

Precipitants

• Underlying Disease progression and loss of liver function
• Hypoglycaemic episodes
• Sepsis: urine, ascites, blood, CSF
• Drugs - diuretics, sedation, alcohol
• Constipation
• GI protein load : dietary input, GI bleed
• Paracentesis
• Paracetamol poisoning

Complications

• Ascites
• Hypoglycaemic episodes
• Spontaneous bacterial peritonitis
• Hepatic encephalopathy
• Hepatorenal syndrome
• Hepatocellular carcinoma

Investigations

• FBC, U&E, glucose, phosphate, LFT, PT, AFP.
• Check coagulation - Prothrombin time
• Blood cultures, MSSU. Ascitic tap (Gram stain, WCC and culture), protein.
• Causes: Viral hepatitis screen. Autoantibody profile. Paracetamol level.
• USS of abdomen.

Management

• ABC, Avoid hypoxaemia, hypotension, and hypoglycaemia by frequent observations. Admit under those with specialist skills.
• If low GCS or new neurology get a CT to exclude SDH/ICH. A low GCS can mean raised ICP or encephalopathy. Consider ITU input.
• Lactulose 30ml oral TDS is beneficial in early encephalopathy. Titrate to produce 2 to 3 bowel movements daily. Use phosphate enemas in more severe cases or if unable to take lactulose.
• Look for sepsis: send blood, urine and ascitic fluid cell count and culture if encephalopathic. Ascitic tap for SBP if WBC>250/microlitre starts Antibiotics. Treat sepsis.
• Manage any drug misuse, sedatives, opiates, diuretics, alcohol withdrawal, drug ingestion, alcohol abuse or has the patient had a GI bleed
• Mange any hyponatraemia - usually due to water excess. Fluid restrict.
• Correct any hypokalaemia, low phosphate, Low Magnesium
• Consider Pabrinex which contains Thiamine if any suggestion at all of the malnourished or B1 deficiency or alcohol abuse
• Send for alpha-fetoprotein if Hepatoma a concern and get USS
• Monitor renal function as at risk of Hepatorenal syndrome

References

• Acute on Chronic Liver disease