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Metabolism: Acute Liver Failure - Coggle Diagram
Metabolism: Acute Liver Failure
Pathophysiology
Inflammation cascade activated by local tissue damage, toxicity, or virus. Hepatocytes are damaged and specialized macrophages in the liver (Kupffer cells) are first line defenses against attack. Neutrophils and pro-inflammatory cytokines are released brought to the site causing vasodilation and increases capillary permeability. This leads to leakage, swelling, and right upper quadrant pain.
Excessive neutrophil invasion of tissue causes apoptosis of hepatocytes and worsens overall liver function. This creates a cycle that attracts more immune cells and inflammatory response at the site that further damages tissue.
Blood flow resistance from cellular inflammation impairs hepatic circulation. Portal hypertension and venous congestion in stomach and kidneys develops. Hepatocytes deprived of oxygenated blood, further reducing their function.
Widespread inflammation causes necrosis of liver tissue. Regeneration of liver tissue is often fibrous scar tissue that alters cellular function. Liver may compensate for an extended period.
The liver fails when it's unable to perform its many functions. It loses its ability to detoxify waste products, metabolize drugs and alcohol, convert proteins, produce clotting factors, regulate glucose and bilirubin, and shunt blood properly.
Hypoalbuminemia from impaired protein synthesis causes water and sodium retention. Release of aldosterone and accumulation of fluid in peritoneal capillaries leads to edema and ascites.
Inability to process bilirubin causes jaundice, or yellowing of the skin due to accumulation
Impaired metabolism of amino acids prevents conversion of ammonia into urea, elevated serum levels cause encephalopathy.
Impaired glucose synthesis causes hypoglycemia
Decreased cholesterol and fat absorption from impaired lipoprotein metabolism and bile salt storage
Bleeding and esophageal varices may occur due to decreased coagulation factors
Etiology: acetaminophen toxicity
Labs/Diagnostics
Increased AST and ALT liver enzymes, bilirubin
Coagulation studies - PTT and INR
Decreased albumin
CBCs to evaluate for thrombocytopenia
Hepatitis test
Symptoms
Pain or swelling in RUQ
Fatigue
Weakness, muscle wasting
Decreased appetite
Bleeding or bruising easily
Encephalopathy, altered mental status
Hypotension
Collaborative Treatment
Educate about liver transplant, establish expectations about treatment
Dietary management
Low sodium
Moderate protein, about 60g daily
Enteral feedings to maintain gastric integrity and promote nutritional status
Pharmacological
Vitamin K for clotting
Antihistamine
Proton pump inhibitor
Fluid replacement with colloid solutions (albumin) over crystalloid (saline)
Correction of electrolyte abnormalities
Monitor glucose levels and address appropriately
Precautions: falls, bleeding, seizures
Monitor VS and LOC frequently
Complications
Coma due to hepatic encephalopathy
Kidney damage from fluid and electrolyte imbalance
Infection
Risk Factors
Alcohol abuse
Acetaminophen use/overdose
Hepatitis risk factors: IV drug use