Acute Liver Failure

By Stephen Holt, MD, PhD, FACP

• What is Acute Liver Failure?
• What are the Causes?
• Who is at Risk?
• What are the Signs and Symptoms?
• How is it Diagnosed?
• Treatment
• Complications
• Prevention
• Suggested Articles

What is Acute Liver Failure?

Acute liver failure (ALF), also known as fulminant liver failure is an uncommon condition which occurs when the liver suddenly ceases to function in an otherwise healthy person. This most severe type of liver failure is life-threatening and develops in a matter of days.

ALF affects about 2000–2800 persons annually (3.5 deaths per million population) and accounts for 5-6% of liver transplants in the United States.

What are the Causes?

The most important aspect in individuals with acute liver failure is to identify the cause because prognosis is dependent on the origin or cause.

Some of the many potential causes include:

• Acetaminophen poisoning (over-the-counter pain reliever) – Taking a very large dose of acetaminophen all at once or a smaller dose over a long period of time, is the leading cause of ALF in the United States, especially in people with chronic liver disease.
• Prescription drugs – Anticonvulsants, antibiotics, nonsteroidal anti-inflammatory drugs and drugs used to treat tuberculosis to name a few.
• Herbal supplements – Pennyroyal, ephedra, skullcap and kava are some of the herbal drugs and supplements that have been linked to ALF. Some fat burners used to increase metabolism have also been a cause.
• Viral hepatitis and other viruses – Hepatitis A, B, C (rarely) D and E with Hepatitis B accounting for the majority of cases. ALF actually occurs in less than 5% of hepatitis viral infections. Other viruses which may cause it include Epstein-Barr virus, Yellow Fever and cytomegalovirus (virus in the herpes family).
• Shock to the liver – Hemorrhage, sepsis (overwhelming infection), heatstroke, heart failure and severe dehydration.
• Toxins – Poisonous mushrooms such as Amanita phalloides, carbon tetrachloride (a manufactured chemical used in cleaning fluids, pesticides and spot removers), chloroform and rat poisons.
• Metabolic diseases – Rare metabolic diseases such as Wilson’s Disease, acute fatty liver of pregnancy and Reye’s syndrome (a deadly disease affecting all organs in the body, especially the liver and thebrain)  infrequently cause acute liver failure
• Vascular diseases – Blockages in the veins of the liver such as portal vein thrombosis (a blood clot or narrowing of the portal vein, which brings blood to the liver from the intestines), Budd-Chiari syndrome (blockage of the vein that carries blood away from the liver), and veno-oclusive disease (blockage of the very small – microscopic -veins in the liver).
• Cancer – Liver cancer or cancer that begins somewhere else in the body and then spreads to the liver.
• Unknown – Many cases have no apparent cause.

Who is at Risk?

Acute liver failure often affects young persons and carries a high morbidity and mortality. Risk factors include:

• People that take an extremely large dose of acetaminophen at one time or a smaller dose over a period of a few days.
• Failure to follow dosage instructions for prescription medications and over-the-counter pain relievers and herbal medicines.
• Failure to follow manufacturer’s instructions when using aerosol sprays, pesticides, cleaning fluids and other toxic chemicals. (Always wear protective clothing such as gloves, a mask, protective eyewear and a hat.)
• Failure to get vaccinated for Hepatitis A and B.
• Use of illicit drugs, engaging in unprotected sex, obtaining a tattoo or body piercing in an unsanitary environment or with unsanitary equipment
• Failure to exercise caution when handling needles or cleaning up bodily fluids or blood.
• Failure to inform one’s doctor of all prescription drugs, herbal remedies and over-the-counter medications that one is taking to prevent dangerous interactions.
• Consumption of excessive amounts of alcohol.
• Obesity – (While obesity is not known to cause ALF, studies show that obese and severely obese patients had significantly poorer outcomes when they developed acute liver failure.)

What are the Signs and Symptoms?

Symptoms come on suddenly and without warning, so it is important to seek medical care immediately. Some of the signs and symptoms include:

• Hepatic encephalopathy (mental confusion, difficulty concentrating and disorientation)
• Sudden jaundice (yellowing of the whites of the eyes and skin)
• Pain and tenderness in the upper right side of the stomach
• Nausea
• Vomiting
• Ascites (accumulation of fluid in the stomach)
• Edema (accumulation of fluid in the legs, ankles and feet)
• Feeling ill
• Drowsiness
• Muscle tremors
• Diarrhea
• Bleeding easily

How is it Diagnosed?

Physical assessment by a healthcare professional, along with blood tests to determine liver function will be performed. Also, when the liver fails, blood doesn’t clot as quickly as it should, therefore a prothrombin time test may be performed to measure how quickly the blood clots.

In cases where the patient may be incapacitated, family members and close friends will need to assist medical personnel in providing patient history.

Finally, examination of liver tissue (biopsy) may also be performed to determine why the liver is failing.

Treatment

Acute liver failure from certain causes demands immediate and specific treatment. It is also critical to identify those patients who will be candidates for liver transplantation.

ALF is treated in the intensive care unit of a hospital. Treatment for can include the following:

• Medications to reverse poisoning such as from an overdose of acetaminophen or mushrooms.
• Medications to relieve fluid buildup in the brain which causes pressure on the brain.
• Medications to clear infections after blood and urine tests show positive results of infection.
• Medications to prevent severe bleeding will be administered as bleeding ulcers in the gastrointestinal tract are often common.
• In the case where liver failure can’t be reversed, a liver transplant is the only treatment. The failed liver is removed and replaced with a new, healthy liver from a donor.

Complications

Acute liver failure often causes complications, some of which are:

• Kidney failure – often occurs following liver failure, especially as a result of acetaminophen poisoning which damages both the liver and the kidneys.
• Bleeding disorders – due to the body’s inability to clot blood properly.
• Infections – respiratory and urinary tract infections are common as well as infections in the blood.
• Cerebral edema (excessive fluid in the brain) – leading to irreversible brain damage and death.
• Coma – Mental confusion, difficulty concentrating and disorientation (hepatic encephalopathy) can progress to coma if liver function does not return.

Prevention

By following dosage directions on all prescription, herbal and over-the-counter medications (including acetaminophen), avoiding risky behavior, exercising caution when using any type of chemicals and living a healthy lifestyle, acute liver failure can be prevented.

If sudden jaundice, tenderness in the upper abdomen or any unusual changes in mental state, personality or behavior occurs, it is imperative that one seeks medical attention right away.

This information is for educational purposes only and should not be used in any other manner. This information is not intended to substitute for informed medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified health care provider.

Suggested Articles

• N-Acetyl Cysteine Treats Acute Liver Failure
• Acetaminophen & Caffeine: Bad Combo for Your Liver

About the Author

Stephen Holt, MD, PhD, FACP

Stephen Holt, M.D. is a Distinguished Professor of Medicine NYCPM (Emerite) and a medical practitioner in New York State. He has published many peer-review papers in medicine and he is a best-selling author with more than twenty books in national and international distribution. He has received many awards for teaching and research. Dr. Holt is a frequent lecturer at scientific meetings and healthcare facilities throughout the world. He is a best selling author and the founder of the Holt Institute of Medicine.