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Acute Liver Failure

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Overview

Acute liver failure describes the rapid development of hepatocellular dysfunction (jaundice, coagulopathy, and hepatic encephalopathy) in a patient without known prior liver disease. If these symptoms occur in a patient with known liver disease, it is described as ‘acute-on-chronic’ liver failure.

A diagnosis of acute liver failure requires the presence of encephalopathy, making it different to acute hepatitis, which does not. 

Classification

Liver failure can be classified as:

  • Hyperacute – within 7 days
  • Acute – between 8 to 28 days
  • Subacute 29 days to 12 weeks

Epidemiology

  • Viral infection is the most common cause globally
  • Paracetamol overdose is the leading cause in the UK

Causes

Presentation

  • Jaundice
  • Hepatic encephalopathy
  • Coagulopathy
  • Right upper quadrant pain
  • Nausea
  • Vomiting
  • Hyperdynamic circulation – hypotension and tachycardia
  • Kidney failure – hepatorenal syndrome may develop due to reduced perfusion

Differential Diagnoses

Severe acute hepatitis

  • Acute liver failure requires encephalopathy to be present, which is not in acute hepatitis
  • Severe acute hepatitis may develop into acute liver failure if encephalopathy develops

Investigations

Overview

  • Liver function tests (LFTs):
    • Increased bilirubin
    • Elevated liver enzymes – usually very high
  • Prothrombin time or INR:
    • Prolonged
  • U&Es:
    • May be deranged if hepatorenal syndrome develops
  • Arterial blood gases:
    • May show metabolic acidosis
    • May show increased lactate

Other investigations

The following investigations may be considered to determine an underlying cause:

  • Viral hepatitis serology
  • Autoimmune hepatitis antibodies
  • Paracetamol levels
  • Serum/urine toxicology
  • Pregnancy tests for acute fatty liver of pregnancy and HELLP syndrome
  • Abdominal ultrasound – for Budd-Chiari syndrome

Management

Overview

1st-line: manage underlying cause + complications

Liver transplantation may need to be considered

Complications

  • Infections and sepsis
  • Hepatic encephalopathy and cerebral oedema
  • Coagulopathy
  • Hepatorenal syndrome
  • Haemorrhage due to varices

Prognosis

  • The prognosis depends on the underlying cause

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