Signs of chronic liver failure are all except -
Pathophysiology Any cause of liver damage can produce acute liver failure, provided it is sufficiently severe . Acute viral hepatitis is the most common cause worldwide, whereas paracetamol toxicity is the most frequent cause in the UK. Acute liver failure occurs occasionally with other drugs, or from Amanita phalloides (mushroom) poisoning, in pregnancy, in Wilson's disease, following shock and, rarely, in extensive malignant disease of the liver. In 10% of cases, the cause of acute liver failure remains unknown and these patients are often labelled as having 'non-A-E viral hepatitis' or 'cryptogenic' acute liver failure Clinical assessment Cerebral disturbance (hepatic encephalopathy and/or cerebral oedema) is the cardinal manifestation of acute liver failure, but in the early stages this can be mild and episodic, and so its absence does not exclude a significant acute liver injury. The initial clinical features are often subtle and include reduced aleness and poor concentration, progressing through behavioural abnormalities, such as restlessness and aggressive outbursts, to drowsiness and coma . Cerebral oedema may occur due to increased intracranial pressure, causing unequal or abnormally reacting pupils, fixed pupils, hypeensive episodes, bradycardia, hyperventilation, profuse sweating, local or general myoclonus, focal fits or decerebrate posturing. Papilloedema occurs rarely and is a late sign. More general symptoms include weakness, nausea and vomiting. Right hypochondrial discomfo is an occasional feature. The patient may be jaundiced but jaundice may not be present at the outset (e.g. in paracetamol overdose), and there are a number of exceptions, including Reye's syndrome, in which jaundice is rare. Occasionally, death may occur in fulminant cases of acute liver failure before jaundice develops. Fetor hepaticus can be present. The liver is usually of normal size but later becomes smaller. Clinical grading of Clinical signs Grade 1 Poor concentration, slurred speech, slow mentation, disordered sleep rhythm Grade 2 Drowsy but easily rousable, occasional aggressive behaviour, lethargic Grade 3 Marked delirium, drowsy, sleepy but responds to pain and voice, gross disorientation Grade 4 Unresponsive to voice, may or may not respond to painful stimuli, unconscious Ref Davidson edition23rd pg857
Subcutaneous nodules
Palmer erythema
Spider nevi
Testicular atropy
G.I.T