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196 Chapter 5: Hepatic, biliary and pancreatic systems

Table 5.3 Child–Pugh grading have a viral cause, most of the remainder being
due to paracetamol poisoning. Other rare but impor-
Grading
system 1 2 3 tant drug-induced causes are halothane, isoniazid and
rifampicin.
Encephalopathy None Grade I–II Grade III–IV
Ascites Absent Mild–moderate Severe
Bilirubin <35 35–50 >50 Pathophysiology
(micromol/L)
Albumin (g/L) >35 28–35 <28 Widespread multiacinar necrosis with or without fatty
Prothrombin 1–3 4–6 >6 change causes a severe loss of liver function. Hepatic
time (seconds encephalopathy is thought to be due to failure of the
over control) liver to metabolise toxins. Serum amino acid levels rise
affectingthebalanceofcerebralneurotransmitters.Hep-
Child–Pugh grade A = score of 5–6; Child–Pugh grade B = score
of 7–9; Child–Pugh grade C = score of 10–15 atic dysfunction also results in renal failure (hepatorenal
syndrome).
Investigations
Aimed at diagnosis of underlying cause and assessment
of severity/degree of reversible liver injury. The severity Clinical features
of liver disease may be graded A–C by means of a mod- Patients may have altered behaviour, euphoria or se-
ified Child–Pugh grading system (see Table 5.3). Liver dation and confusion (see Table 5.4). Fever, vomiting
biopsy is often required for assessment. abdominal pain and bleeding may also occur.
On examination patients are jaundiced, there may be
Management fetor hepaticus (sickly sweet odour on breath), flapping
Treatment is largely supportive. Withdrawal from alco- tremor, slurred speech, difficulty in writing and copy-
hol is essential in all patients. Malnutrition is common ing simple diagrams (constructional apraxia) and gen-
and may require nutritional support. Liver transplanta- eralised hypertonia.
tion may be required when end stage liver failure occurs.
Prognosis Complications
Cirrhosis is an irreversible, progressive condition which Central nervous system: Cerebral oedema in 80%
oftencontinuestoend-stageliverfailuredespitethewith- causing raised intracranial pressure.
drawal of precipitating factors. The higher the Child– Cardiovascular system: Hypotension, arrhythmias
Pugh grade, the worse the prognosis, particularly for due to hypokalaemia including cardiac arrest.
death from bleeding varices or following surgery. Respiratory system: Respiratory arrest.
Gastrointestinal system: Haemorrhage, pancreatitis.

Genitourinary system: Acute renal failure due to hep-
Fulminant hepatic failure
atorenal failure or acute tubular necrosis.
Definition Metabolic: Hypoglycaemia, hypokalaemia.
The rapid development of severe hepatic failure caus- Haematology: Coagulopathy.
ing encephalopathy and impaired synthetic function in Infections.
aperson who previously had a normal liver or had well-
compensated liver disease.
Table 5.4 Grading of hepatic encephalopathy
Incidence
Grade I Altered mood or behaviour
Rare Grade II Increasing drowsiness, confusion, slurred
speech
Aetiology Grade III Stupor, incoherence, restlessness, marked
confusion
Anycauseofanacutehepatitismayprogresstofulminant
Grade IV Coma
hepaticfailure.Over50%ofcasesintheUnitedKingdom