Hepatic failure is a complex of symptoms that are characterized by a violation of one or more liver functions due to damage to the parenchyma. The liver is unable to maintain the constancy of the internal environment in the body due to inability to meet the needs of metabolism in the internal environment.
Hepatic insufficiency includes two forms: chronic and acute. But still it is possible to allocate 4 degrees of hepatic insufficiency: a coma, dystrophic (terminal), decompensated (expressed), compensated (initial). It is not excluded the development of lightning-fast liver failure, in which the likelihood of a lethal outcome is quite high.
The disease can provoke the development of encephalopathy - a symptom-complex of various disorders of the central nervous system. This is a rare complication, in which a lethal outcome reaches 90%.
The pathogenetic mechanism of hepatic insufficiency distinguishes:
- endogenous hepatic insufficiency (hepatic-cellular), which proceeds, affecting the parenchyma of the liver;
- exogenous (portocaval, portosystem). Toxins, ammonia, phenol, are absorbed into the intestines, and then enter the total blood flow through the portocaval anastomoses from the portal vein;
- mixed includes the above mechanisms.
Hepatic failure of the cause
The development of acute liver failure is most often due to the presence of various liver diseases or acute viral hepatitis. The formation of hepatic encephalopathy in the acute form of the disease can occur quite rarely, but not later than the 8th week from the onset of the manifestation of the first symptoms.
The most common causes of hepatic insufficiency are medication and lightning-fast form of viral hepatitis A, B, C, D, E, G. And also due to poisoning with carbon dioxide, aflatoxin, mycotoxin, industrial toxins, alcohol abuse, medication, septicemia . Viruses of shingles and simple lichens, infectious mononucleosis, herpes and cytomegaloviruses also often provoke the development of this disease.
Chronic hepatic failure is formed in the presence of progression of chronic liver disease ( cirrhosis , malignant neoplasms). The most often develops severe hepatic insufficiency in people with hepatitis A at the age of more than 40 years, who were previously diagnosed with liver disease (most often it's drug addicts). The greatest threat is hepatitis E for pregnant women, as in 20% of cases hepatic insufficiency develops.
Infectious diseases ( tuberculosis , yellow fever), adenovirus, herpes simplex virus, cytomegalovirus , Epstein-Barr virus, are much less likely to lead to the development of hepatic insufficiency.
In case of drug overdose Paracetamol liver failure may occur. The lower the dosage of the drug, the less lesions of the liver, and the prognosis is more favorable. Analgesic drugs, sedatives, diuretics rarely provoke the development of hepatic insufficiency. However, some fungi (Amanita phalloides, etc.) can lead to the development of this condition.
Poisoning with toxoid can lead to the formation of hepatic insufficiency on 4-8 days, and the lethal outcome reaches 25% of cases. Also, poisoning with yellow phosphorus, aflatoxin, carbon tetrachloride and other toxins can cause the disease to form.
Hypoperfusion of the liver, which develops due to the Badd-Chiari syndrome, veno-occlusive disease, chronic heart failure , can lead to the development of hepatic insufficiency. Massive infiltration of tumor cells with metastases or lymphoma (pancreatic adenocarcinoma, small cell lung cancer ), Wilson-Konovalov's disease and other metabolic liver diseases that can manifest with symptoms of liver failure contribute to the development of the disease.
The rare cause of hepatic insufficiency is: heat shock resulting from hyperthermia, liver resection with cirrhosis, dull trauma, surgical intervention (transgular intrahepatic portosystemic or portocaval shunting), Reye syndrome, acute fatty liver dystrophy in pregnant women, autoimmune hepatitis, galactosemia , tyrosinemia, erythropoietic protoporphyria.
It is possible the development of the disease due to electrolyte disorders (hypokalemia), conditions that are accompanied by increased protein content in the intestine (a diet with a large number of proteins, gastrointestinal bleeding).
Fulminant hepatic insufficiency is mainly the result of hereditary diseases (Wilson-Konovalov's disease), autoimmune and viral hepatitis, and as a result of drug intake (Paracetamol) and poisoning with toxic substances (eg, pallid grebe toxins).
Because of acute metabolic stress, electrolyte metabolism disorders, infections, bleeding from varicose veins in patients with chronic liver disease and portosystemic shunts, hepatic encephalopathy may occur. Also, the reasons for the formation of hepatic encephalopathy can be: parabdominocement, hepatocellular carcinoma , increased protein level in the daily diet (if there are severe liver diseases), the progression of chronic liver disease, alcohol abuse, drug intake (Paracetamol, diuretics, sedatives, opioids, Codeine) , spontaneous peritonitis in the presence of ascites, infectious diseases of the chest and urinary tract organs, esophageal and gastrointestinal bleeding.
The formation of hepatic encephalopathy in liver failure is probably associated with impaired electrolyte blood composition and acid-base balance (azotemia, hypochloraemia, hyponatremia, metabolic acidosis , hypokalemia, metabolic and respiratory alkalosis ). Also, with hepatic insufficiency, there are violations of hemodynamics and homeostasis: hyper and hypothermia, changes in hydrostatic and oncotic pressure, collateral blood flow and portal hypertension , dehydration, hypovolemia, bacteremia, hypoxia.
Encephalopathy, according to theory, develops under the influence of toxic substances (tyrosine, phenylalanine, phenol, ammonia) that penetrate the blood-brain barrier, accumulating in the brain, disrupt the functions of the cells of the central nervous system.
Hepatic Insufficiency Symptoms
In the case of impaired functions of the central nervous system, patients with hepatic insufficiency will exhibit symptoms of encephalopathy. The most rare manifestations are mania and motor anxiety. The disease is characterized by tremor (lateral movements of the fingers occur with a sharp flexion-extensor movement in the wrist and metacarpophalangeal joint). Symmetric will be neurological disorders. In patients who are in a coma, there will be symptoms of damage to the trunk in the brain a few days or hours before the death.
In patients with hepatic insufficiency, you can identify increased jaundice and neuritis. It is possible that an increase in body temperature and peripheral ascites and swelling. There will be a liver specific odor from the mouth, which is caused by the formation of dimethyl sulfide and trimethylamine. Perhaps, the manifestation of endocrine disorders ("the phenomenon of white nails", telangiectasia, atrophy of the uterus and milk glands, baldness , gynecomastia, infertility , textile atrophy, decreased libido).
The compensated stage of hepatic insufficiency is manifested by increased jaundice, fever, hemorrhage, adynamy, sleep disorders, mood and behavior.
The expressed decompensated stage of hepatic insufficiency is manifested by the intensified symptoms of the previous stage (sweating, drowsiness, "clapping tremor", slurred speech, fainting, dizziness , disorientation, possible aggression, inadequate behavior and liver odor from the mouth).
The terminal stage of hepatic insufficiency is manifested by broken contact while maintaining an adequate response to pain, confused consciousness, cries, anxiety, agitation, difficult awakening, stupor.
The hepatic coma is accompanied by loss of consciousness, at first spontaneity of movements and reaction to pain, which further completely disappear. There is a strabismus divergent, pupillary reaction is absent, there is a slowing of the EEG rhythm, stiffness and convulsions. As the coma becomes deeper, the amplitude will decrease. Hepatic encephalopathy manifests itself clinically as reversible disorders of cognitive function, consciousness, discoordination of movements, tremor, monotonous speech, drowsiness.
0 stage of hepatic encephalopathy is manifested by minimal symptomatology: no tremor, minimal disruption of coordination of movements, cognitive functions, concentration of attention, memory impairment.
Stage 1 of hepatic encephalopathy is accompanied by a sleep disorder and a violation of its rhythm, a violation of the counting, a decrease in attention, a slowed ability to perform tasks (intellectual), irritability and euphoria.
In the 2 stages of hepatic encephalopathy one can observe a small disorientation in space and time, a violation of the subtraction account, ataxia , dizziness, asterixis, slurred speech, inadequate behavior, apathy and lethargy .
Stage 3 is manifested by comparison, significant disorientation in space and time, amnesia, dysarthria, attacks of anger.
At 4 stages of hepatic encephalopathy, a coma develops when the reaction to the pain stimulus is completely absent.
Acute liver failure
Occurs when the liver suddenly loses its ability to perform its functions. Often there is a slowly progressing liver failure, however, the acute form of the disease is formed over several days and has severe complications or results in a fatal outcome.
Acute liver failure is due to:
- drug overdoses (Efferalgan, Tylenol, Panadol, anticonvulsants, painkillers, antibiotics);
- Abuse of folk remedies (biological supplements, poisoning with marsh mint, sculpin, cava, ephedra);
- Herpes virus, Epstein-Barr virus, cytomegalovirus, viral hepatitis A, B, E, and other viral diseases;
- Poisoning by various toxins capable of neutralizing the combination of liver cells (poisonous fungi);
- the presence of autoimmune diseases;
- diseases of the veins of the liver;
- metabolic disorders;
- Oncological diseases.
Signs of acute hepatic insufficiency: nausea and vomiting, yellowing of the sclera of the eyes, mucous membranes and skin, malaise, pain in the upper right abdominal area, disorientation, inability to concentrate, drowsiness and lethargy.
Chronic liver failure
Chronic hepatic insufficiency arises from the progressively developing liver dysfunction due to the progressive course of the chronic parenchyma disease. As a rule, the symptoms of the underlying disease manifest themselves. Appear dyspeptic phenomena ( diarrhea , vomiting, anorexia ), fever, jaundice, encephalopathy.
Severe hepatic insufficiency arises from the presence of cholelithiasis, tuberculosis, helminthiases, fatty hepatosis , oncological diseases, cirrhosis, viral or autoimmune hepatitis, alcohol dependence. In rare cases, chronic hepatic insufficiency is formed due to a genetic metabolic disorder - glycogenase, galactosemia, etc.
Symptoms of chronic hepatic insufficiency: nausea, anorexia, vomiting and diarrhea. The symptomatology of disturbed digestion arises from the use of smoked foods, fried and fatty foods. Perhaps, the appearance of undulating fever, jaundice, skin lesions (hepatic palms, dry and wet eczema , hemorrhages). Early signs of the disease are ascites and peripheral edema.
Chronic liver failure is manifested by endocrine disorders: atrophy of the uterus and mammary glands, alopecia, gynecomastia, testicular atrophy, infertility. Neuropsychiatric disorders are manifested in the form of: irritability, aggressiveness, inadequate behavior, loss of orientation, deafness, periodic co-morbidity, anxiety, insomnia and drowsiness, memory loss, depression .
Treatment of hepatic impairment
The goal of the treatment is the therapy of the underlying disease, which contributed to the development of hepatic insufficiency, as well as the prevention and treatment of hepatic encephalopathy. Also, the therapy will depend entirely on the degree of liver failure.
When treating acute liver failure, the following conditions must be observed:
- an individual nursing position;
- Monitoring of urine, blood sugar and vital functions every hour;
- monitor serum potassium 2 times a day;
- a daily blood test to determine the level of albumin, creatine, be sure to evaluate the coagulogram;
- the physiological solution administered intravenously is contraindicated;
- Prophylaxis of pressure sores.
In chronic liver failure, it is necessary:
- to actively monitor the general condition, taking into account the increased symptoms of encephalopathy;
- weighing daily;
- daily to measure daily diuresis (the ratio of the amount of fluid allocated to the consumed one);
- daily blood test for the determination of creatine, electrolyte;
- every two weeks the level of albumin, bilirubin activity of alkaline phosphatase, AlAT, AcAt;
- regular execution of the coagulogram, measuring the level of prothrombin;
- in the case of the last stage of cirrhosis, it is necessary to take into account the possibility of liver transplantation.
Treatment of chronic hepatic insufficiency is carried out according to the following scheme:
- in the daily diet, the patient is restricted to intake of table salt and protein (no more than 40 g / day);
- Ciprofloxacin is injected intravenously (1.0 g 2 r./day), without waiting for the determination of sensitivity to antibacterial drugs and the result of bacteriological examination;
- Ornithine in the first stage is administered 7 times intravenously (daily dose - 20 g), dissolving in 500 ml of Sodium Chloride or Glucose.
- At the second stage of treatment, Hepa-Mertz is administered for two weeks three times a day (18 g per day);
- Within 10 days for 5-10 ml twice daily, Hofitol is administered;
- Normase (Dyufaak, Lactulose) in the initial daily dosage is introduced 9 ml with a sequential increase to the development of a small diarrhea. This helps to reduce the absorption of ammonia;
- with constipation is necessary with magnesium sulfate enema (20 g per 100 ml of water);
- Vikasol (vitamin K) intravenously 3 times a day for 1 mg;
- with blood loss, it is necessary to inject freshly frozen plasma intravenously to 4 doses, and in case of prolonged bleeding repeat after 8 hours;
- the introduction of salt solutions is categorically prohibited;
- It is necessary to take a complex of vitamins with the additional introduction of folic acid. The management of magnesium, phosphorus and calcium helps maintain adequate mineral metabolism;
- Kvametel (famotidine) should be administered intravenously 3 r / day, diluting in 20 ml of saline solution to 20 mg;
- To increase the caloric content of food, enteral feeding through the probe is necessary.
To treat bleeding, you should not conduct arterial punctures and inject fresh-frozen plasma intravenously, as well as famotidine 3 times a day.
In order to cure the infection, antibacterial therapy is needed. For proper medical selection, you need to make a culture of blood and urine. If there is a catheter in the vein, you need to collect the material from it. Ciprofloxacin 2 times a day to be injected intravenously at 1.0 g. With catheterization of the bladder, development of oliguria or anuria is possible, in this case it is necessary to irrigate ursectically 2 times a day.
There are specialized hepatological centers where patients with stage 3-4 hepatic encephalopathy through a large porous polyacrylonitrile membrane undergo hemodialysis. Due to this, removal of low-molecular substances (ammonia and other water-soluble toxins) takes place.
With the development of fulminant hepatitis with hepatic encephalopathy, liver transplantation is performed if:
- Patients over 60 years of age;
- normal liver function preceding this disease;
- in case of the possibility of maintaining the post-transfusion regime for a long time in full volume after liver transplantation.
For the treatment of hepatic encephalopathy, diet therapy is primarily used to reduce the level of ammonia in the blood and protein in the diet. Increased protein content helps to worsen the overall condition. In the daily diet should include vegetable products.
In order to cleanse the intestines, it is necessary to take laxatives or to hold regular enemas. It should be taken into account that 2 times a day the intestine should be emptied.
Antibiotic therapy is carried out under strict control of the functionality of the liver. 1 g Neomycin 2 times a day, 25 mg Metronidazole 3 times a day, 0.5 g Ampicillin up to 4 times a day.
Haloperidol is prescribed as a sedative if the patient has significant motor anxiety. When the central nervous system is damaged, benzodiazepines should not be administered.