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HEPATIC FAILURE

HEPATIC FAILURE. DR.M.H.Mumtaz. Topics . Anatomy Histology Liver Functions Liver Function Tests Liver Failure Management in ICU. ANATOMY . Wt . 1.8 - 2 Kg Blood supply = 25 % CO Topography = 2 Lobes subdivided into lobules

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HEPATIC FAILURE

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  1. HEPATIC FAILURE DR.M.H.Mumtaz

  2. Topics • Anatomy • Histology • Liver Functions • Liver Function Tests • Liver Failure • Management in ICU

  3. ANATOMY • Wt . 1.8 - 2 Kg • Blood supply = 25 % CO • Topography = 2 Lobes subdivided into lobules • Rt Lobe =have 2 suspended Lobes Caudate Lobe quadrate Lobe

  4. Liver Blood Flow • Total = 1100 -1800 ml / min 25 % CO • Hepatic artery = 30 – 40 % = O2 supply = 40 - 55 % = Saturation = 98 % = flow = sphincteric mechanism

  5. Liver Blood Flow • Hepatic Portal vein = 70 % B. flow =50 - 60 % O2 supply = po2 = 50 mm Hg = blood velocity = 9 cm/sec • Hepatic arterio-venous reciprocity

  6. Blood Flow PCO2 Hepatitis Supine Posture Food Drugs Beta stimulants Phenobarbitone Enzyme inducers Blood Flow IPPV + PEEP Surgery PCO2 , Hypoxia Upright posture Cirrhosis Drugs alpha stimulants Beta blockers Ganglion blockers Ranitidine Pitressin Anaesthetics Liver Blood Flow

  7. Histology zone 1 - receives blood with spo2 zone 2 - intermediate zone 3 - receives blood with spo2

  8. Important Liver Functions • Carbohydrate Metabolism 1. Glycogen synthesis 2. Glycogenolysis 3. Gluconeogenesis

  9. Important Liver Functions • Lipid Metabolism • Synthesis of Lipoproteins • Phospholipids • Cholesterol • Endogenous Triglycerides • Excretion of breakdown products of cholesterol • Ketone synthesis

  10. Important Liver Functions • Protein Synthesis • Vitamin .D metabolism • Vitamin A, B, B12. stored in liver • Iron store • Excretion & Detoxication • Reticuloendothelial function

  11. Liver Function Tests • Static Tests • Dynamic Tests

  12. Liver Function (Static )Tests • Liver cell damage • Transaminases • Lactate dehydrogenase • Liver cell dysfunction • Serum Proteins • Coagulation factors - PT, APTT • Serum Bilirubin • Biliary Tract obstruction • Alkaline Phosphatase • Gama-glutamyl Transferase • Bilirubin • Tests Indicating aetiology

  13. ROLE OF VIT K LIVER ----------VIT. K WARFARIN -------gamma glutamyl carboxylase ADDS carboxyl group to glutamic acid residue ON Factors, 2nd,7th,9th & 10th. Proteins S,C,&Z ( activation) PROTHROMBIN TIME(PT)

  14. HEPARINES ANTITHROMBINS(SERINE PROTEASE INHIBITOR) DEGRADE THROMBIN,F9a, F10a,F12a ( serine proteins) HEPARIN increase adhesion of antithrombins to factors

  15. Functional ( Dynamic) Tests • Impaired Lactate clearance (lactate level) • Clearance of organic substances • Anionic dye – Indocyanine green (ICG) • Formation of metabolites • Monoethylglycinxylidid from lidocain (MEGX)

  16. Topology of Liver Damage • Diffuse Parenchymal damage • Periportal damage • Pericentral damage

  17. Response to injury • Necrosis • Degeneration • Steatosis • Regeneration • Inflammation • Fibrosis

  18. ETIOLOGICAL FACTORS • NON . INFECTIOUS • Alcohol • Drug related • Reyes’ Syndrome • Pregnancy • INFECTIOUS DAMAGE • Fungal • Protozoal • Malaria • Parasites • Liver abscess

  19. Aetiology 3. Viral Infections a. Systemic Viral infection • Infectious mononucleosis • cytomegalovirus • Herpes virus • In children ( rubella, adenovirus enterovirus)

  20. Aetiology, 3. Viral infections b. Hepatotropic Viruses • Hepatitis A virus (HAV) • Hepatitis B virus (HBV) • Hepatitis C virus (HCV) • Delta Hepatitis virus (HDV) • Hepatitis E virus ( HEV ) • Others – ( F,G…. ? )

  21. 4. Inborn Errors of metabolism • Primary Haemochromatosis • Wilsons’ Disease • Alpha – 1 – Antitrypsin deficiency

  22. 5. Tumours • Benign • Malignant

  23. LIVER FAILURE MANIFESTATIONS • Hepatic Manifestations • Jaundice • Coagulopathy • Extrahepatic Manifestations • Encephalopathy • Hepato-renal Syndrome • Susceptibility to infections

  24. MANAGEMENT IN ICU • General Intensive Care • Enteral nutrition • Stress ulcer prophylaxis • Glucose Homeostasis • Antibiotic prophylaxis / SDD • Control Intracranial Hypertension • Albumen • Vasopressor for HRS

  25. MANAGEMENT • Specific Therapy- Antidote • Monitoring by. PDR – ICG • Extracorporeal Support • Liver Transplant

  26. Hepatic Encephalopathy • Toxic Metabolites • ammonia,glutamine • ^ ICP • Ippv,Mannitol,Hypothermia • Hypertonic saline • Vasopressors--caution

  27. Hepatorenal Syndrome • 1, Marked renal vasoconstriction • RBF decreased • GFR decreased • 2,Absence of histological changes • 3,Preserved tubular renal function

  28. HRS Pathogenesis Portal hypertension/Liver failure 1, Increased level of ; NO, CO. 2, Spanchnic arterial vasodilation 3,Low effective circulating volume 4, Activation of systemic endogenous vasoconstrictors 5, Svere renal vasoconstriction

  29. HRS Diagnostic criteria • Major criteria CHF +Portal hypertension Low GFR Absence-shock,infection,drug dehydration No improovement after,removal of diuretics, pv expansion Proteinurea <500mg/dl

  30. HRS Diagnostic criteria • Minor criteria Urine volume<500ml/d Urine sod.excretion<10mmol/l urine osmolality/plasma osm>1 No finding in urine sediment Natremia <130mmol/l All major criteria +a few minor to support

  31. HRS TYPES Type 1, Type 2 Rapidly progressive---RF with out rapidly progressive Acute r.failure-------------Refractory ascites

  32. HRS Precipitating events spontaneus bacterial peritonitis paracentesis without plasma expan GIT haemorrhage Severe acute alcoholic hepatitis Unknown

  33. HRS THERAPY TIPS (transjugular intravenous portosystamic s.) + Albumin,vasoconstrictors MARS (molecular adsorbant recycling system)

  34. New therapies -HRS Albumin+trlipressin Albumin+Midodrine+octreotide Albumin+Noradrenaline

  35. Extracorporeal Liver Support

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