Chronic Liver Failure - Management

Management – general

Patients with liver failure often deteriorate quickly. If patients are not unwell enough for resuscitation beds they should be placed in a highly visible bed with a cardiac monitor. For patients who require intubation / inotropic support / ICU care one must assess the appropriateness of these interventions, the reversibility of the situation and the prognosis for the patient. The Child-Pugh score can be used to help determine prognosis.

Management - specific

Alcohol

  • Thiamine IV 200mg stat and continue IV 200mg 8 hourly – there is no consensus on route, dose, frequency. Patients with Wernickes encephalopathy may need doses up to 500mg IV

  • Multivitamins for nutritional deficiencies, replace electrolytes

  • Glucose as have lost gluconeogenic powers – give thiamine prior to glucose load

  • Alcohol withdrawal scale and oral diazepam

  • Lactulose 20mLs QID

  • Education about abstinence

  • Work out Maddreys Discriminant Function (MDF) score. Patients with MDF ≥32 have a poor prognosis. Discuss with gastroenterology. They may benefit from:

    • Steroids – minimal data but there is a suggestion that steroids have a protective effect - start 40mg/day if no contraindications.

    • Anticytokine therapy – pentoxifylline – oral phosphodiesterase inhibitor which decreases production TNF? and other cytokines.

Ascites

  • Indications for paracentesis include abdominal pain and SOB

  • Check inr/plt and for relative contraindications like adhesions, bowel obstruction

  • Send sample for albumin, cytology, cell count, culture

  • If large amount (>6L) to be drained then replace volume with human albumin solution (no evidence for use if less than this). Once paracentesis complete 100mLs 20% albumin / 3l ascites.

  • Na restriction (plus water restriction if Na

  • Spironolactone +/- frusemide

  • Link to Life In The Fast Lane Paracentesis video

Spontaneous Bacterial Peritonitis (SBP)

  • SBP is infection of ascitic fluid without clear source such as perforation / abscess (secondary bacterial peritonitis).

  • Diagnosis – Ascitic fluid - Polymorph cell count >250cells/mm? or positive fluid culture.

  • Typical organisms Klebsiella, E coli, Strep pneumoniae.

  • Treatment - If SBP suspected treat empirically with Cefotaxime 2g 8 hourly.

  • Stop ? blockers – it has been found non selective ? blockers increase haemodynamic instability, time of hospitalisation, and risks for hepatorenal syndrome and acute kidney injury.

Coagulopathy

  • PO vit K 10mg TDS

  • Platelet transfusion if plt

  • Active haemorrhage FFP +/- recombinant factor VIIa - discuss with Haematologist

Encephalopathy

  • Lactulose 20mLs QID

  • Early intubation if required to protect airway. Prior to this one must first make an assessment about the appropriateness of this intervention.

  • Link to grades

Variceal Bleeding

Hepato-renal Syndrome

  • Caused by extreme renal artery vasoconstriction in setting of splanchnic vasoldilation, low cardiac output and low effective plasma volume.

  • Plasma expansion with albumin (100mLs 20% HAS) +/- haemodialysis plus vasoactive agents like octreotide or norad.

  • Paracentesis has been found to improve renal function in volume resuscitated patients.

Hepato-pulmonary syndrome (HPS)

  • Tense ascites can cause pleural effusions and splint the diaphragm however true HPS is a disorder of pulmonary vascular dilatation and shunting.

  • Supplemental oxygen mainstay of treatment.

  • For refractory hypoxaemia, liver transplant is considered and higher priority given to those with liver failure and HPS.

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