Acute Liver Failure
Liver is the most important site of metabolism in the body. Hence, it is natural that whatever we take orally, gets metabolized in the liver before going into circulation. Liver damage caused by toxins such as aflatoxin (fungal), yellow phosphorus poisoning (rat killer poison) and other chemicals is called toxic hepatitis.
When a person with no pre-existing liver illness, develops jaundice followed by progression into altered sensorium and coma (called hepatic encephalopathy), it is defined as acute liver failure. Acute liver failure is less common though than chronic liver failure, which develops more slowly.
Acute liver failure, also known as fulminant hepatic failure, can cause serious complications and even death.
Acute liver failure is a medical emergency that requires urgent hospitalization in a centre with advanced liver intensive care because early initiation of treatment can save the life potentially. It causes an excessive build-up of fluid in the brain (cerebral edema), bleeding disorders including inability to clot easily and difficult to control bleeding in the gastrointestinal tract, susceptibility to serious infections, and even kidney failure.
Depending on the cause and level of liver damage, acute liver failure can sometimes be reversed with treatment. In most situations, though, a liver transplant may be the only cure.
The following are common causes for acute liver failure, but in about 15% of patients, the cause is unknown.
- An over dose (more than the recommended dose) of paracetamol is the most common cause especially in the Western world. Acute liver failure can occur after one very large dose of paracetamol, or after higher than recommended doses every day over several days
- Some prescription medications, including antibiotics, non-steroidal anti-inflammatory drugs and anticonvulsants
- Herbal drugs and supplements have been linked to cause acute liver failure
- Hepatitis viruses A, B and E can cause acute liver failure. Hepatitis C rarely causes acute liver failure. Hepatitis B virus is a likely more common cause as it is more prevalent. Other viruses that can cause acute liver failure include Epstein-Barr virus, cytomegalovirus and herpes simplex virus.
- Toxins such as consuming poisonous wild mushrooms, exposure to the industrial chemical carbon, and other insecticides. Rat Killer poisoning especially in Southern india
- Autoimmune hepatitis, by which the body’s own immune system attacks liver cells causes inflammation and considerable liver damage
- Vascular diseases, such as Budd-Chiari syndrome, can cause sudden blockages in the veins of the liver and lead to acute liver failure
- Rare causes include metabolic diseases such as Wilson’s disease and fatty liver of pregnancy can present as Fulminant crises
- Yellowing of the skin and whites of the eyes (jaundice)
- Pain in the upper right abdomen
- Loss of appetite
- Breath may have a musty sweet odor
- Nausea and vomiting
- A general sense of being unwell with fatigue and weakness (malaise)
- Disorientation or confusion (encephalopathy)
- Increased sleepiness/drowsiness
- Low blood pressure
- Increased tendency to bruise very easily
- Difficulty in breathing
- Low urine output if kidney damage has occurred
- The most important step in the assessment of patients is to identify the cause, because certain conditions necessitate immediate and specific treatment. Tests may have to be repeated frequently for continuous assessment of progress or further deterioration.
- Careful evaluation of the mental status is important
- Blood tests
- o Prothrombin time (PT) test measures how long it takes for blood to clot. The PT is prolonged
- International normalized ratio (INR), a calculation based on the PT test, is greater than 1.5
- Liver enzymes are elevated: Aspartate aminotransferase (AST)/serum glutamic-oxaloacetic transaminase (SGOT), alanine aminotransferase (ALT)/serum glutamic-pyruvic transaminase (SGPT), alkaline phosphatase (ALP)
- Bilirubin is elevated
- Test for the presence of hepatitis virus infections
- Ammonia level is increased
- Urine test
- Computerized tomography (CT) scanning will show the expansion of brain due to water accumulation which is a bad sign and requires urgent attention before the patient progresses into permanent brain damage.
- Reversing or limiting the effects of toxins, such as the use of acetylcysteine, activated charcoal
- Mannitol to reduce brain swelling if present
- Intravenous fluid replacement, with glucose
- Blood transfusion, possibly with clotting factors
- Ventilator to assist breathing
- Anti-edema measures to reduce pressure inside the brain
- Continuous renal replacement therapy or 24-hour slow dialysis to reduce the ammonia load
- Therapeutic plasmapheresis as a supportive system for the liver in certain situations
- It is important to triage these patients at admission, start intensive care immediately
- If transplant criteria fulfilled implying that chance of spontaneous recovery are slim, then patient should be urgently listed for transplant before it is too late and sick for transplant.
- Timely liver transplant can potentially cure the patient.
- During a liver transplant, a surgeon removes the damaged liver and replaces it with a healthy liver from a donor.
- Follow instructions of all medications in the recommended doses
- Use over-the-counter and herbal medicines with caution
- Limit the amount of alcohol intake to no more than one drink a day for women of all ages and men older than 65 and no more than two drinks a day for younger men.
- Do not use illegal drugs and avoid sharing needles
- Use condoms during sex
- Tattoos or body piercings must be done in a safe, clean and hygienic environment
- Get the hepatitis A and B vaccines
- Avoid sharing razor blades or toothbrushes
- Do not get tempted to eat wild mushrooms
- Use caution while using insecticide sprays, and paint sprays
After progression to acute liver failure:
Ultrasound may show liver damage
Acute liver failure requires intensive care unit admission in a hospital that can perform a liver transplant, if necessary.
Medical management includes:
The only recommended treatment when certain criteria such as Kings College criteria are fulfilled based on clinical presentation and the lab test results at admission.
Exciting research is going on regarding bioartificial liver support systems, transplanting healthy cells of the liver instead of the entire organ to see if they can regenerate and replace the damaged and failed liver. However, they are still in experimental stage and not recommended as standard of care at present.
It is important to reduce the risk of acute liver failure and its serious complications.