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Acute Liver Failure

by | 4 Dec, 2020

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Introduction

Acute liver failure is an uncommon condition whereby serious complications of liver disease rapidly present (within 8 weeks) following the appearance of precipitating illness. This usually occurs in the absence of pre-existing liver disease.

Causes

Any cause of liver damage can produce acute liver failure. Causes include:

  • Drugs (70-80% of cases): paracetamol overdose, anti-tuberculosis drugs, halothane
  • Viral (5%): hepatitis A, hepatitis B
  • Acute fatty liver of pregnancy
  • Budd-Chiari syndrome
  • Shock
  • Liver metastases
  • Lymphoma
  • Idiopathic

Pathophysiology

Failure occurs when there is insufficient metabolic and synthetic function. It can occur in the absence of pre-existing liver disease (fulminant liver failure) or with pre-existing chronic liver disease.

Clinical features

There are a wide variety of clinical features, although cerebral disturbances are the cardinal manifestation.

  • Cerebral disturbance (e.g. hepatic encephalopathy, cerebral oedema). Initiali manifestiations indluce poor concentration, restlessness and drowsiness. Cerebral oedema can lead to neurological signs, including fixed pupils, bradycardia, hyperventilation and focal fits
  • Jaundice
  • Fetor hepaticus
  • Ascites and peripheral oedema are late features of acute liver failure

Investigations

Bloods:

  • LFT and GGT: check for raised bilirubin, ALT and ALP
  • Clotting studies: prolonged INR and APTT in advanced cirrhosis
  • Ferritin: raised in haemochromatosis
  • FBC: check for anaemia (gastrointestinal bleeding) and macrocytosis
  • U&E: check for hepatorenal syndrome
  • Viral serology: hepatitis A-E, EBV, CMV
  • Autoantibodies: ANCA, ANA, AMA
  • Immunoglobulin levels: IgM, IgG
  • Caeruloplasmin: reduced in Wilsons’s disease
  • Alpha1-antitrypsin levels

Imaging:

  • Ultrasound scan: check liver size, shape and elasticity
  • Doppler scan of hepatic veins: check for presence of clots

Management

Patients require urgent transfer to ITU. Monitor and treat complications, which may include cerebral oedema, hypoglycaemia, renal failure, metabolic acidosis and infection. N-acetylcysteine can be used in cases of paracetamol poisoning.

Liver transplants are often required.

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