Acute and Chronic Liver and Biliary Impairment 

1. Acute Liver and Biliary Impairment 

Definition 
Acute liver impairment refers to a rapid loss of liver function, often over days to weeks, leading to metabolic, synthetic, and detoxification failure. Acute biliary impairment can present as obstruction or infection of bile ducts, sometimes leading to sepsis. 

A. Causes 

1. Drug/Toxin Overdose 

Acetaminophen (paracetamol): Most common cause of acute liver failure in developed countries. 
Overdose → hepatocyte necrosis → raised transaminases, coagulopathy. 

Other hepatotoxins: 
Alcohol (acute binge) 
Herbal/OTC supplements 
Certain antibiotics (e.g., amoxicillin-clavulanate (Augmentin)) 
Chemotherapy agents 

2. Viral Hepatitis 

Hepatitis A, B, E can rarely cause fulminant hepatitis. 

3. Ischaemic Hepatitis 

“Shock liver” due to hypoperfusion in critical illness. 

4. Autoimmune or Metabolic 

Autoimmune hepatitis, Wilson’s disease, acute fatty liver of pregnancy. 

5. Biliary Causes / Sepsis 

Ascending cholangitis: infection of biliary tract, usually due to obstruction (stones, strictures, tumours). 
Charcot’s triad: Fever, jaundice, right upper quadrant pain. 
Severe cases → Reynolds pentad: adds hypotension and confusion → septic shock. 

B. Pathophysiology 

Hepatocyte injury → release of AST/ALT. 
Impaired synthetic function → coagulopathy (INR ↑), hypoalbuminemia. 
Impaired detoxification → hyperbilirubinemia, encephalopathy. 
Biliary obstruction → cholestasis, bacterial overgrowth → sepsis. 

C. Clinical Features 

Acute liver failure: jaundice, fatigue, nausea, vomiting, abdominal pain, confusion (hepatic encephalopathy), coagulopathy. 
Biliary sepsis: fever, right upper quadrant pain, jaundice, hypotension in severe cases. 

D. Investigations 

Bloods: AST, ALT, ALP, GGT, bilirubin, INR, albumin, full blood count. 
Toxins: acetaminophen (paracetamol) levels. 
Imaging: Ultrasound/CT for biliary obstruction. 
Blood cultures: if sepsis suspected. 
Additional: viral serology, autoimmune markers, metabolic screens. 

E. Management 

1. Supportive Care 
ICU monitoring for acute liver failure. 
Correct coagulopathy, manage hypoglycaemia. 
Treat encephalopathy (lactulose, rifaximin). 

2. Specific Therapy 

Acetaminophen (paracetamol) overdose → N-acetylcysteine (NAC) infusion. 
Biliary sepsis → antibiotics + urgent biliary drainage (ERCP or percutaneous). 

3. Transplant Consideration 

Indicated in acute liver failure with poor prognostic markers. 

2. Chronic Liver Impairment 

Definition 

Chronic liver disease (CLD) develops over months to years, often leading to fibrosis and cirrhosis, and impaired synthetic, metabolic, and detoxification function. 

A. Causes 

Alcoholic liver disease (ALD): most common cause in Western countries. 
Chronic viral hepatitis (B, C) 
Non-alcoholic fatty liver disease (NAFLD/NASH) 
Autoimmune hepatitis, hemochromatosis, Wilson’s disease 

B. Pathophysiology 
Repeated injury → hepatocyte necrosis → fibrogenesis → cirrhosis. 
Portal hypertension develops due to architectural distortion. 
Complications: varices, ascites, hepatic encephalopathy, hepatocellular carcinoma. 

C. Clinical Features 
Early: often asymptomatic, fatigue, malaise. 
Progressive: jaundice, spider angiomas, palmar erythema, hepatosplenomegaly. 

Complications: 
Ascites: fluid accumulation in peritoneum. 
Variceal bleeding: from portal hypertension. 
Hepatic encephalopathy: confusion, asterixis. 
Coagulopathy: easy bruising, prolonged INR. 

D. Investigations 
Bloods: LFTs, INR, albumin, platelet count. 
Imaging: ultrasound for liver architecture, ascites. 
Endoscopy: screen for varices. 
Liver biopsy or non-invasive fibrosis markers: assess severity. 

E. Management 

1. Alcoholic Liver Disease 
Complete abstinence from alcohol. 
Nutritional support: thiamine, folate. 
Treat complications: diuretics for ascites, beta-blockers for varices. 

2. General Chronic Liver Disease 
Manage portal hypertension, hepatic encephalopathy. 
Vaccinate against hepatitis A/B if susceptible. 
Surveillance for hepatocellular carcinoma (ultrasound ± AFP every 6 months). 

Key Teaching Points 

Acute liver failure is a medical emergency; recognize early signs (confusion, coagulopathy). 
Biliary sepsis often requires rapid antibiotics and drainage. 
Acetaminophen (paracetamol) overdose: time-critical intervention with NAC. 
Chronic liver disease: identify early and prevent progression; monitor for complications. 
Alcohol is both a direct toxin and a major contributor to chronic liver impairment. 

Nurses play a key role in monitoring mental status, fluid balance, and medication safety in liver disease.