[N109] Acute Liver Failure

A. Rapid deterioration of liver function with altered mentation and coagulopathy

Acute liver failure is best described as:
A. Rapid deterioration of liver function with altered mentation and coagulopathy
B. Chronic cirrhosis over many years
C. Fatty liver that’s asymptomatic
D. Alcoholic hepatitis only

A. Change in mental state (encephalopathy)

Altered mentation in acute liver failure refers to:
A. Change in mental state (encephalopathy)
B. Only short-term memory loss
C. Only headache
D. Persistent euphoria

a. 1.5

Coagulopathy in acute liver failure is defined by an INR ≥:
A. 1.5
B. 1.0
C. 2.5
D. 3.5

False

True / False
Question: Acute liver failure occurs only in patients with preexisting chronic liver disease.

A. Fulminant hepatic failure (fulminant hepatitis)

Question: Another name for acute liver failure is:
A. Fulminant hepatic failure (fulminant hepatitis)
B. Chronic hepatic failure
C. Nonalcoholic fatty liver disease
D. Hepatomegaly syndrome

Viral myocarditis

1. Question: Which is NOT a progressing condition of liver failure?

• Subfulminant liver failure

• Hyperacute liver failure

• Subacute hepatic necrosis

• Viral myocarditis

A. Cerebral edema and intracranial hypertension

The most serious neurologic complication of acute liver failure is:
A. Cerebral edema and intracranial hypertension
B. Peripheral neuropathy
C. Bell’s palsy
D. Migraine

A. Hypotension, tachycardia, decreased vascular volume with vasodilation

Typical hemodynamic effects in acute liver failure include:
A. Hypotension, tachycardia, decreased vascular volume with vasodilation
B. Hypertension and bradycardia
C. No hemodynamic change
D. Only increased cardiac output

True

True / False
Question: ARDS (acute respiratory distress syndrome) is a recognized complication of acute liver failure.

True

True / False
Sepsis is a possible complication of acute liver failure.

A. Kupffer cell function and removal of endotoxins (and decreased PMN motility)

Which immune functions are decreased in acute liver failure?
A. Kupffer cell function and removal of endotoxins (and decreased PMN motility)
B. Antibody production increases
C. Complement activity increases
D. Neutrophil function improves

A. TNF and IL-6

Acute liver failure is associated with increased levels of which cytokines?
A. TNF and IL-6
B. Insulin and glucagon
C. Epinephrine only
D. Dopamine only

A. Multiple organ failure

A severe multisystem outcome that may follow acute liver failure is:
A. Multiple organ failure
B. Isolated skin rash only
C. Benign recovery always
D. Only chronic fatigue

A. INR (international normalized ratio)

Which lab test is used to assess coagulopathy in acute liver failure?
A. INR (international normalized ratio)
B. HbA1c
C. Serum amylase
D. Urine ketones

A. Severe complement deficiency and decreased PMN motility (and impaired Kupffer cell function)

Why are patients with acute liver failure more prone to infections?
A. Severe complement deficiency and decreased PMN motility (and impaired Kupffer cell function)
B. High antibody levels protect them
C. Improved neutrophil function
D. Enhanced Kupffer clearance

A. Lungs (ARDS), kidneys, brain, and circulatory collapse

Which organ systems commonly fail during ALF-related multi-organ failure?
A. Lungs (ARDS), kidneys, brain, and circulatory collapse
B. Only the liver fails
C. Only spleen fails
D. Only pancreas fails

A. Altered mentation + coagulopathy (INR ≥ 1.5) + no prior liver disease

Which triad raises immediate suspicion for acute liver failure (ALF)?
A. Altered mentation + coagulopathy (INR ≥ 1.5) + no prior liver disease
B. Jaundice only
C. Chronic ascites + varices
D. Stable mental status

True: INR ≥ 1.5 indicates clinically significant coagulopathy due to impaired hepatic synthesis of clotting factors — a diagnostic criterion for ALF.

True / False
INR ≥ 1.5 supports the diagnosis of acute liver failure.

FALSE: PTT can also be prolonged in ALF because multiple clotting factors decline. PTT changes are relevant and help assess coagulopathy.

True / False
Q: An increase in PTT ≥ 4 seconds is irrelevant when suspecting ALF.

A. Acidosis (Multi-organ dysfunction and impaired metabolism can produce acidosis in ALF.)

Which acid–base pattern is commonly seen in patients with ALF suspicion?
A. Acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis only
D. No imbalance

A. Transfer to ICU for monitoring and support

ALF can deteriorate rapidly (encephalopathy, cerebral edema, bleeding), so ICU-level monitoring/support is indicated.

What immediate action is commonly taken when ALF is suspected?
A. Transfer to ICU for monitoring and support
B. Send home with oral meds
C. Outpatient referral only
D. Wait 72 hours to observe

A. Acute hepatitis A–E or HBV reactivation

Which of the following is a viral etiology that can precipitate ALF?
A. Acute hepatitis A–E or HBV reactivation
B. Type 1 diabetes
C. Osteoarthritis
D. Migraine

A. Acetaminophen (paracetamol)

Acetaminophen overdose (or use with potentiating factors like alcohol) is a top cause worldwide.

Which common over-the-counter drug is a leading cause of drug-induced ALF?
A. Acetaminophen (paracetamol)
B. Ibuprofen
C. Vitamin C
D. Penicillin

FALSE: Amatoxins (Amanita) resist cooking; ingestion of a few mushrooms can later cause severe hepatotoxicity and ALF.

True / False
Q: Amanita mushroom toxins are destroyed by cooking.

A. < 20 years old

Wilson’s (copper overload) often manifests in adolescents/young adults and can present acutely.

Wilson’s disease presenting as ALF is most likely to occur in which age group?
A. < 20 years old
B. > 60 years old
C. Newborns only
D. Middle-aged adults only

A. Cardiac tamponade or acute heart failure

Severe hypoperfusion causes massive centrilobular necrosis and can precipitate ALF.

Which event can cause ischemic hepatitis (“shock liver”) leading to ALF?
A. Cardiac tamponade or acute heart failure
B. Eczema flare
C. Rheumatoid arthritis flare
D. Migraine attack

A. Obstructing hepatic venous outflow leading to ischemia

Budd–Chiari syndrome causes ALF by:
A. Obstructing hepatic venous outflow leading to ischemia
B. Increasing bile production
C. Enhancing liver regeneration
D. Reducing portal pressure

FALSE: The liver tolerates substantial resection; ALF risk rises with removal of ~80% of healthy liver or when resection is done on already-dysfunctional liver.

True / False
Q: Removing 30% of a healthy liver commonly results in ALF.

A. IgM anti-HBc positive; HBsAg often positive

Which lab pattern supports acute HBV-related ALF?
A. IgM anti-HBc positive; HBsAg often positive
B. Only HBsAb positive
C. Normal ALT only
D. Low bilirubin only

A. Amanita mushrooms (amatoxins)

Which toxin has a very low lethal dose and classically causes ALF after a phase of severe GI symptoms?
A. Amanita mushrooms (amatoxins)
B. Lead
C. Mercury
D. Arsenic only

True

Alcohol induces CYP enzymes and depletes glutathione, increasing formation of acetaminophen’s hepatotoxic metabolite and reducing detoxification capacity.

True / False
Q: Acetaminophen plus chronic alcohol use lowers the threshold for hepatotoxicity.

True

Extensive replacement of hepatic parenchyma impairs synthetic and metabolic function, potentially causing ALF.

True / False
Q: Massive malignant infiltration of the liver (e.g., leukemia, lymphoma, metastases) can precipitate ALF.

A. Uncommon; ~75% survival rate

Hepatitis A as a cause of ALF is:
A. Uncommon; ~75% survival rate
B. The most common cause
C. Always fatal
D. Only with co-infection

A. Herpes, Varicella-Zoster, Epstein–Barr

Other viral agents that can cause ALF include:
A. Herpes, Varicella-Zoster, Epstein–Barr
B. HIV only
C. Rhinovirus
D. Norovirus

A. HBsAg, IgM Anti-HBc, HBV DNA

Markers for acute HBV-related ALF include:
A. HBsAg, IgM Anti-HBc, HBV DNA
B. HBeAb only
C. HBsAb only
D. ALT only

A. Alcohol intake & continued use after jaundice

Acetaminophen toxicity risk increases with:
A. Alcohol intake & continued use after jaundice
B. Vitamin C only
C. Antibiotics only
D. Never alcohol

FALSE: Amatoxins resist cooking; a few mushrooms can be lethal and ALF may follow days later.

True / False
Q: Amanita mushroom toxins are destroyed by cooking.

A. Green tea <///33

Which herbal product can cause HILI or herb-induced liver injuries?
A. Green tea
B. Ginger
C. Turmeric
D. Garlic

A. Chlorinated hydrocarbons, yellow phosphorus

Which chemicals/toxins are named as ALF causes?
A. Chlorinated hydrocarbons, yellow phosphorus
B. Asbestos
C. Benzene
D. Household bleach

A. Budd–Chiari syndrome

Which syndrome causes hepatic venous outflow obstruction?
A. Budd–Chiari syndrome
B. Carpal tunnel syndrome
C. Nephrotic syndrome
D. Irritable bowel syndrome

True: Wilson’s may present acutely in adolescents/young adults and can be a presenting feature.

True / False
Q: Wilson’s disease can present as ALF in young patients.

A. Acute fatty liver of pregnancy

Which pregnancy liver disease is an ALF etiology?
A. Acute fatty liver of pregnancy
B. Ectopic pregnancy
C. Hyperemesis only
D. Placenta previa

A. AFLP, Reye's syndrome, valproic acid toxicity

Microvesicular steatosis is linked to:
A. AFLP, Reye's syndrome, valproic acid toxicity
B. Alcoholic steatosis only
C. Hep C only
D. Pancreatitis only

True

Severe hypoperfusion causes centrilobular necrosis and can precipitate ALF.

True / False
Q: Ischemic hepatitis can result from cardiac tamponade.

A. OLT issues, graft rejection, vessel thrombosis, large hepatectomy

Which transplant/surgical events can trigger ALF?
A. OLT issues, graft rejection, vessel thrombosis, large hepatectomy
B. Appendectomy
C. Cholecystectomy
D. Hernia repair

A. Post-BMT, chemotherapy, irradiation

Veno-occlusive disease (VOD) is linked to:
A. Post-BMT, chemotherapy, irradiation
B. Running marathons
C. High-fiber diet
D. Allergic rhinitis

True

Extensive tumor replacement impairs hepatic function and can precipitate ALF.

True / False
Q: Massive malignant infiltration can cause ALF.

A. Reye’s syndrome

Which pediatric syndrome linked to aspirin causes microvesicular steatosis?
A. Reye’s syndrome
B. Kawasaki disease
C. Henoch–Schönlein purpura
D. Croup

Because ALF has multiple possible etiologies, and a thorough history helps identify viral infections, autoimmune diseases, drug/toxic exposures, dietary supplements, hobbies, and onset of jaundice.

Why is history taking very important in acute liver failure (ALF)?

FALSE

Is asking about occupation/hobbies irrelevant in ALF?

Jaundice

What is a hallmark physical sign of hepatic decompensation?

C. Chronic kidney disease (Rationale: ALF focuses on liver-related etiologies, not pre-existing kidney disease.)

Which of the following is NOT a hallmark in ALF history taking?
A. Recent cold sores
B. Autoimmune disease
C. Chronic kidney disease
D. Drug/toxic exposure

Bradycardia (Rationale: ALF usually presents with tachycardia, not bradycardia.)

Identify the item that doesn’t belong in physical assessment of ALF:

• Jaundice

• Ascites

• Hepatomegaly

• Bradycardia

ALT, AST

Elevated _____ and _____ levels indicate hepatocellular injury in ALF.

A. Ceruloplasmin and serum/urine copper

Which lab test is most important to rule out Wilson’s disease in young ALF patients?
A. Ceruloplasmin and serum/urine copper
B. PT/PTT
C. Bilirubin
D. ALT/AST

FALSE: Reserved for diagnostic dilemmas (e.g., AIH) to reduce bleeding risk.

True or False: Liver biopsy in ALF is performed routinely in all patients.

Cardiac Output ÷ Body Surface Area

Cardiac Index is calculated as _____ ÷ _____ .

D. All of the above

Which of the following viral infections can lead to ALF?
A. Herpes simplex
B. Epstein-Barr virus
C. Varicella-Zoster
D. All of the above

AST (Rationale: AST indicates hepatocellular injury, not synthetic function.)

Which lab does NOT directly assess liver synthetic function?

• Albumin

• PT/INR

• AST

• Bilirubin

right

After a transjugular liver biopsy, the patient should lie on their _____ side to prevent bleeding.

FALSE: To rule out acute fatty liver of pregnancy.

True or False: Pregnancy test is unnecessary in young females with ALF.

jaundice, ascites, altered sensorium, and hepatic tenderness

Common signs of hepatic decompensation include ?

B. Rising creatinine and oliguria

Which of these is a poor prognostic sign in ALF?
A. Normal creatinine
B. Rising creatinine and oliguria
C. Normal blood pressure
D. Mild AST elevation

Blood type (Rationale: ALF assessment focuses on causes, not ABO type.)

Which is NOT a part of ALF history taking?

• Drug exposure

• Viral infection

• Hobbies and occupation

• Blood type

Electrolytes, albumin, magnesium, phosphate, CBC, PT/PTT, and viral markers

Which markers should be checked to assess liver function in ALF?

D. All of the above

Which autoimmune markers are useful in ALF workup?
A. ANA
B. ASMA
C. Immunoglobulin levels
D. All of the above

FALSE: Certain herbs like green tea can induce liver injury (HILI), especially in Asian populations.

True or False: Herbal/dietary supplement history is irrelevant in ALF assessment.

FALSE: Only patients with onset of hepatic encephalopathy and poor prognostic signs require urgent OLT referral.

True or False: All ALF patients require immediate transfer to orthotopic liver transplantation (OLT).

4, 1.5

Prolonged PT ≥ ___ seconds or INR ≥ ___ is a hallmark of ALF.

A. Younger age (<40 years) (Rationale: Younger patients tolerate ALF better; the other options are poor prognostic factors.)

Which factor improves prognosis in ALF?
A. Younger age (<40 years)
B. Presence of cerebral edema
C. Delay between jaundice and HE >3 weeks
D. Multi-organ failure

Beta-blockers for HTN control (Rationale: HTN management focuses on avoiding volume overload; beta-blockers are not standard.)

Identify the item that is not a management strategy in ALF ICU care:

• Central line for dextrose

• Monitoring ICP

• Enteral feeding for grade 3-4 coma

• Beta-blockers for HTN control

A. ICP < 20-25 mmHg, CPP > 50-60 mmHg

Ideal ICP and CPP targets in ALF patients are:
A. ICP < 20-25 mmHg, CPP > 50-60 mmHg
B. ICP > 25 mmHg, CPP < 50 mmHg
C. ICP < 10 mmHg, CPP < 40 mmHg
D. ICP > 30 mmHg, CPP > 70 mmHg

FALSE: Mannitol is used specifically to reduce cerebral edema in ALF, not general metabolic issues.

True or False: Mannitol is used in ALF to prevent metabolic complications.

5

Pantoprazole is given in ALF to maintain gastric pH above ____.

D. Hyperthyroidism (Rationale: Thyroid disease is unrelated to ALF complications.)

Which is NOT a complication of ALF?
A. ARDS
B. Multi-organ failure
C. Cerebral edema
D. Hyperthyroidism

Diuretics (Rationale: Temporary measures focus on toxin removal or bridging to OLT; diuretics manage fluid, not toxins.)

Which is not used for temporary toxin removal in ALF?

• Hemodialysis

• Charcoal hemoperfusion

• Extracorporeal liver support

• Diuretics

rises

Early renal support should be initiated if creatinine ___ or oliguria develops.

D. All of the above

Which is a correct medical intervention in ALF?
A. FFP for bleeding
B. Epinephrine or norepinephrine for hypotension
C. Enteral feeding with 60 g protein/24 hrs
D. All of the above

FALSE: Reserved for grade 3-4 coma or patients awaiting OLT.

True or False: ICP monitoring is recommended for all ALF patients.

Central line (with FFP, albumin, or dextrose)

Volume expansion in ALF is typically administered via ___ .

B. Liver transplantation (OLT)

What is the definitive treatment for ALF?
A. Hemodialysis
B. Liver transplantation (OLT)
C. Charcoal hemoperfusion
D. Extracorporeal liver perfusion

Sedation with benzodiazepines routinely (Rationale: Sedation is avoided unless needed for ICP management or intubation.)

Which of these is not part of supportive management for ALF?

• Vasopressors

• Phosphate/magnesium replacement

• Sedation with benzodiazepines routinely

• Early renal support