Question 18

Highest mark

7.9

Using the headings of history, examination, biochemical findings, haematological findings, imaging and biopsy, compare and contrast the clinical features and investigation findings of Acute Fulminant Hepatic Failure with Decompensated Chronic Liver Disease

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College answer

	Acute Fulminant	Decompensated Chronic
History	Acute, toxic ingestion (examples) Viral Infections, Ischaemia Post-surgery	Chronic Liver disease Encephalopathy GI Bleeding
Examination	Jaundice	Jaundice
	Coma	Coma
	Intracranial hypertension common	Intracranial hypertension rare
	No signs chronic liver disease	Signs chronic liver disease
	No ascites	Ascites/oedema
	No portal hypertension	Signs of Portal hypertension
Biochemistry	Hypoglycaemia common	Hypoglycaemia rare
	Hyponatraemia rare	Hyponatraemia common
	Severe acidosis	Mild acidosis
	High Bilirubin	High Bilirubin
	LFT’s severely deranged	LFT’s mildly deranged
	Renal failure common	Renal failure less common
Haematology	Platelets usually normal	Platelets usually low
	INR very high	INR mildly raised
	Fibrinogen low	Fibrinogen normal
Imaging
Head	Cerebral oedema	No cerebral oedema
Abdomen	Normal – may show swollen liver or vascular cause of fulminant failure	Small fibrotic/cirrhotic liver, splenomegaly, varices.
Biopsy	Necrosis	Fibrosis

Discussion

This question is well-formed and gives an accurate impression of exactly what the college wanted to from this comparison of Inappropriately Capitalised Conditions.

Differences between Acute and Chronic Liver Failure
Domain	Acute fulminant hepatic failure	Decompensated chronic liver disease
History	Abrupt onset Clear antecedent cause, eg. toxin ingestion like paracetamol, or trauma, or ischaemia	Gradual onset Associated virus (eg. Hep C) Associated toxin exposure (eg. alcohol)
Examination	Acute lung injury Systemic inflammatory response, vasodilated state SvO₂ is high because of hyperdynamic circulation Decreased level of consciousness due to cerebral oedema Euvolaemic and without ascites Well-nourished No evidence of portosystemic shunting (thus, no varices)	SvO₂ is an unreliable marker of tissue perfusion, because of all the shunts. Confusion and delirium due to hepatic encephalopathy Fluid-overloaded, with ascites Portal hypertension is present (thus, varices) Malnourished Spider naevi
Biochemistry	High ammonia level Normal urea Extremely high LFTs Acute renal failure	Ammonia may be normal Low urea (unless bleeding) Normal-ish LFTs
Haematology	Initially, normal coags INR may be elevated	Chronically low levels of clotting factors
Imaging	US/CT: enlarged liver, hypodense, heterogenous echogenicity	US/CT: small liver, irregular contours, increased density, hyperechoic. Dilated portal vein, evidence of portal hypertension
Biopsy	"Acute necrosis" is what it usually says (i.e. it is often uninformative)	Discriminates between different causes Diagnostic for cirrhosis Useful for prognosis
CT brain	Cerebral oedema	No cerebral oedema

Credit was given to any additional correct answers under the relevant headings.

References

Oh's Manual: Chapter 44 (pp. 501) Liver failure by Christopher Willars and Julia Wendon

Kim, Tae Yeob, and Dong Joon Kim. "Acute-on-chronic liver failure." Clinical and molecular hepatology 19.4 (2013): 349.

Bernal, William, et al. "Acute liver failure." The Lancet 376.9736 (2010): 190-201.

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