FRCA Notes

Hepatic disease

The curriculum asks us to "demonstrate knowledge of liver failure", presumably moreso than just acknowledgement of its existence...

In a CRQ topic on 'liver disease' from September 2022 (77% pass rate), candidates "struggled with the pharmacological component of the question".

Following the March 2021 CRQ on sedation in liver disease (69% pass rate), examiners lamented poorly answered questions on "the effects of liver disease on cardiovascular/respiratory systems & pharmacokinetics"

Conversely, the September 2020 CRQ on hepatic surgery (50% pass) saw "sections on liver anatomy and physiology answered well"

Related topics

  • Liver disease encapsulates a spectrum of pathological processes that cause impaired hepatic synthetic or metabolic functions
  • The incidence of liver disease is increasing, and it is associated with high perioperative morbidity and mortality, especially end-stage disease with cirrhosis and portal hypertension
  • Liver disease can be classified according to aetiology, but perhaps more commonly it is done so temporally

Acute liver failure

  • This triad of jaundice, coagulopathy and encephalopathy describes new onset liver injury in a patient without pre-existing liver disease/cirrhosis
  • It can be further sub-classified using the O'Grady system, which describes the disease in terms of time from jaundice to encephalopathy
    • <7 days = hyperacute
    • <28 days = acute
    • <12 weeks = subacute
  • It is covered further in the ICM section of the site (see link above)

Chronic liver failure

  • A progressive deterioration of hepatic function over a period >28 weeks

Acute-on-chronic liver failure

  • A syndrome of rapid onset hepatic (and extra-hepatic) organ dysfunction in the context of known chronic liver disease
  • Characterised by severe, systemic inflammation and extra-hepatic organ failure
  • Carries a high 28-day mortality
  • Acute decompensation can occur due to a number of factors, such as:
    • Vascular e.g. hypovolaemia or hypotension, variceal bleeding
    • Infection inc. SBP, flare of hepatitis, new infection
    • Impaired homeostasis e.g. electrolyte or fluid imbalance from diuretic drugs, drinking
    • Excessive dietary protein