Liver failure – the sharp or chronic syndrome which is developing at violation of one or several functions of a liver, followed by metabolic frustration, intoxication, violations of activity of TsNS and development of a hepatic coma. The disease proceeds with the phenomena of pechenochnokletochny insufficiency (jaundice, hemorrhagic, dispepsichesky, edematous syndromes, fever, weight loss) and hepatic encephalopathy (emotional lability, apathy, violations of the speech, a tremor of hands, an ataxy). As extreme degree of a liver failure serves development of a hepatic coma. The liver failure is revealed on the basis of biochemical indicators of blood, EEG, a gepatostsintigrafiya. Treatment of a liver failure is directed to elimination of intoxication, normalization of electrolytic violations, restoration of acid-base balance.
The liver failure develops at massive dystrophic, fibrous or necrotic changes of a parenchyma of a liver of various etiology. In gastroenterology and hepatology allocate the sharp and chronic course of a liver failure. As the leading pathogenetic link of a liver failure serves violation of dezintoksikatsionny function of body in this connection toxic products of metabolism (ammonia, γ-aminooleic acid, phenols, , fatty acids, etc.) cause damage to TsNS. Development of electrolytic violations (gipokaliyemiya), metabolic acidosis is characteristic. The lethality at a liver failure reaches 50-80%.
Classification of a liver failure
On a clinical current distinguish a sharp and chronic liver failure. Development of an acute liver failure comes no later than 2 months from the moment of damage of a liver. Most often fulminantny (lightning) forms of viral hepatitis, alcoholic, medicinal or other toxic damage of a liver act as the reason of sharp insufficiency. The chronic liver failure is caused by progressing of chronic diseases of a liver (tumors, fibrosis, cirrhosis, etc.).
The liver failure can develop on the endogenous, exogenous or mixed mechanism. Death of hepatocytes and switching off from functioning over 80% of a hepatic parenchyma is the cornerstone of endogenous insufficiency that is usually observed at acute viral hepatitises, toxic damage of a liver. Development of an exogenous liver failure is connected with violation of a hepatic blood-groove that leads to intake of the blood saturated with toxic substances from a vorotny vein in the general circle at once, passing a liver. The exogenous mechanism takes place at the shunting interventions concerning portal hypertensia and cirrhosis more often. The mixed liver failure arises in the presence of both pathogenetic mechanisms – endogenous and exogenous.
In development of a liver failure allocate three stages: (dekompensirovanny), terminal dystrophic and hepatic coma initial (compensated), expressed. In turn, the hepatic coma is also developed consistently and includes phases of a prekoma, the menacing coma and a klinicheyoska of the expressed coma.
Reasons of a liver failure
In developing of a liver failure the leading role is played by infectious damages of a liver viruses, bacteria, parasites. Viral hepatitises act as the most frequent reason of a liver failure: hepatitis B (47% of cases), hepatitis A (5%), hepatitises C, D and E. Against the background of viral hepatitises the liver failure develops at patients more often 40 years having diseases of a liver, abusing alcohol and narcotic substances are more senior. Less often developing of a liver failure is connected with infection with Epstein-Burra's viruses, simple herpes, adenovirus, a cytomegalovirus, etc.
The etiologichesky factors of a liver failure following on frequency are medicines and toxins. So, the overdose of paracetamol, analgetics, sedative medicines, diuretics can cause massive damage to a hepatic parenchyma. Serve as the strongest toxins causing the phenomena of a liver failure poison of a pale toadstool (), mycotoxin of fungi of a sort (aflatoxin), chemical compounds (four-chloride carbon, yellow phosphorus, etc.).
In some cases the liver failure can be caused by hypoperfusion of the liver arising in connection with a venookklyuzionny disease, chronic heart failure, Badda-Kiari's syndrome, profuzny bleeding. The liver failure can develop at massive infiltration of a liver tumor cells of a lymphoma, metastasis of lung cancer, pancreatic cancer.
Carry sharp fatty dystrophy of a liver, autoimmune hepatitis, an erythropoetic protoporfiriya, a galactosemia, a tirozinemiya to the rare reasons of a liver failure, etc. In some cases development of a liver failure is connected with operational interventions (portokavalny shunting, transjyugulyarny intra hepatic portosistemny shunting, a liver resection) or a stupid injury of a liver.
As the factors provoking failure of compensatory mechanisms and development of a liver failure violations of electrolytic balance (gipokaliyemiya), vomiting, a diarrhea, interkurrentny infections, abuse of alcohol, gastrointestinal bleedings, , the excess use of proteinaceous food, etc. can act.
Symptoms of a liver failure
The clinical picture of a liver failure includes syndromes of pechenochnokletochny insufficiency, hepatic encephalopathy and a hepatic coma. In a stage of pechenochnokletochny insufficiency jaundice, teleangioektaziya, hypostases, ascites, the phenomena of hemorrhagic diathesis, dyspepsia, belly-aches, fever, weight loss appears and progresses. At a chronic liver failure the endocrine violations which are followed by decrease by a libido, infertility, a testicular atrophy, a ginekomastiya, an alopetion, an atrophy of a uterus and mammary glands develop. Violation of processes of metabolism in a liver is characterized by emergence of a hepatic smell from a mouth. Laboratory tests at this stage of a liver failure reveal increase of level of bilirubin, ammonia and phenols in blood serum, a gipokholesterinemiya.
In a stage of hepatic encephalopathy mental violations are noted: instability of an emotional state, a vstrevozhennost, apathy, a sleep disorder, orientations, are possible excitement and aggression. Neuromuscular frustration are shown by indistinctness of the speech, violations of the letter, the "clapping" tremor of fingers of hands (asteriksisy), an incoordination of movements (ataxy), increase in reflexes.
As terminal stage of a liver failure serves the hepatic coma. In a phase of a prekoma drowsiness, slackness, confusion of consciousness, short-term excitement, muscular twitchings, spasms, a tremor, a rigidnost of skeletal muscles, pathological reflexes, an uncontrollable urination appear. Bleeding of gums, nasal bleedings, gemorragiya from a digestive tract can be noted. The hepatic coma proceeds with lack of consciousness and reaction to painful irritants, fading of reflexes. The face of the patient gets masklike expression, pupils extend and do not react to light, HELL decreases, pathological breath (Kussmaul, Cheyna-Stokes) appears. As a rule, in this stage of a liver failure there occurs death of patients.
Diagnosis of a liver failure
When collecting the anamnesis with suspicion of a liver failure find out the facts of abuse of alcohol from patients, the postponed viral hepatitises, the available diseases of a metabolism, chronic diseases of a liver, malignant tumors, reception of medicines.
The research of clinical blood test allows to reveal anemia, . According to a koagulogramma koagulopatiya signs are defined: decrease in PTI, trombitsitopeniye. At patients with a liver failure the dynamic research of biochemical tests is necessary: , alkaline phosphotazy, gamma , bilirubin, albumine, sodium, potassium, creatinine, BRAIDS.
At diagnosis of a liver failure consider data of ultrasonography of abdominal organs: by means of an ekhografiya estimate the liver sizes, a condition of a parenchyma and vessels of portal system, tumoral processes in an abdominal cavity are excluded. By means of a gepatostsintigrafiya diffusion damages of a liver are diagnosed (hepatitises, cirrhosis, fatty ), liver tumors, the speed of biliarny secretion is estimated. If necessary inspection at a liver failure is supplemented with MPT and MCKT of an abdominal cavity.
The electroencephalography serves as the main way of detection of hepatic encephalopathy and the forecast of a liver failure. At development of a hepatic coma on EEG delay and reduction of amplitude of waves of rhythmic activity is registered Morphological these biopsies of a liver differ depending on the disease which led to a liver failure. Hepatic encephalopathy is differentiated with a subduralny hematoma, a stroke, abscess and tumors of a brain, encephalitis, meningitis.
Treatment of a liver failure
At a liver failure the diet with strict restriction or an exception of protein is appointed; at a stage of a prekoma probe or parenteral food is provided.
Treatment of a liver failure includes actions for desintoxication, improvement of microcirculation, normalization of electrolytic violations and acid-base balance. For this purpose intravenously enter large volumes of 5% of solution of glucose, cocarboxylase, pan-quinsies, B6, B12 vitamins, to the essentsiala, lipoic acid. For elimination of ammoniac intoxication and binding of the ammonia which is formed in an organism appoint solution of glutamic acid or ornitsetit.
For reduction of absorption of toxic substances clarification of intestines by means of laxatives and enemas is carried out; appoint the short courses of antibioyotik of a wide range and a laktuloza suppressing processes of rotting in intestines.
Forecast and prevention of a liver failure
At timely intensive treatment of a liver failure of dysfunction of a liver are reversible, the forecast favorable. Hepatic encephalopathy in 80-90% passes into a terminal stage of a liver failure – a hepatic coma. At a deep coma most often there comes the lethal outcome.
Timely therapy of diseases of a liver, exception of hepatotoxic influences, medicinal overdoses, alcoholic poisonings is necessary for the prevention of a liver failure.