Acute Liver Failure

Acute liver disease is a disease of the liver in which there is a sudden loss of liver function within 26 weeks of the liver disease along with encephalopathy and an increase in the INR ratio of more than 1.5. It usually occurs in young persons. The liver mainly has the metabolic function which removes the toxic material from the body and also has got secretary function. When the liver fails to do its function there is an accumulation of waste products causing changes in the central nervous system can also lead to another organ failure also.

Acute failure occurs in a patient who has the preceding liver disease of any cause. The main cause of liver failure includes viral hepatitis Hip A, B, E, D, HSV, VZV, CMV, Drugs toxicity, and metabolic disorders. Acute liver failure usually presents with jaundice followed by mental alteration

Acute liver failure is a life-threatening condition hence diagnosing the condition early and treating it on time is more important. The causing factors should be treated adequately and can also be prevented by a healthy lifestyle, avoiding alcohol, and avoiding abusing various drugs mainly acetaminophen which causes liver toxicity

Acute Liver Failure Causes

• Viral Hepatitis − Hepatitis A & B account for most of these cases, and Hepatitis C rarely can cause. Hepatitis D, as a co-infection or superinfection with HBV, can lead to ALF. Hepatitis E usually observed in pregnant women in an endemic area is an imp cause. Other viral infections like HSV, CMV, EBV, Hemorrhagic fever viruses, and paramyxoviruses, can also cause acute liver failure.

• Acetaminophen hepatotoxicity − It is one of the main causes. Acetaminophen toxicity is a dose-related toxin, when the dose exceeds 10gm/day(150mg/kg) can cause liver toxicity

• Other drug toxicity − include antibiotics, ant tubercular drugs, anticonvulsants, NSAIDs, Mushroom poisoning, etc

• Metabolic diseases like Wilson’s disease

• Vascular Ischemic hepatitis

• Budd-Chiari syndrome

• Acute hepatic vein thrombosis

• Pregnancy-related acute fatty liver or HELPP syndrome which has hemolysis, elevated liver enzymes, and low platelet count

• Autoimmune-related liver failure − Uncommon cause typically occurs in young patients, accompanied by the abrupt onset of Coombs negative hemolytic anemia

• Malignant infiltration −Malignant infiltration of the liver occurs in breast Ca, small cell lung carcinoma, lymphoma, melanoma & myeloma.

Acute Liver Failure Symptoms

Patients with acute liver failure mainly present non-specific symptoms. Which include?

• Fatigue, malaise, lethargy

• Nausea and vomiting

• Anorexia

• Abdominal pain

As the liver failure progress, patients develop jaundice and mental status changes such as lethargy, difficulty sleeping, confusion and eventually coma.

Acute Liver Failure Risk Factors

Following are the risk factors that may lead to Acute Live Failure −

• Patients taking high dose of acetaminophen(paracetamol) without physician opinion

• Alcohol abuse

• Risk factors for viral hepatitis such as travel, blood transfusion, sexual contacts, occupation, body piercing

• Herbal or traditional medicine use

• Family history of liver disease such as Wilson’s disease

• Exposure to hepatic toxins such as mushrooms, organic solvents

Acute Liver Failure Diagnosis

The diagnosis of acute liver failure is based on the History, physical examination, and investigations

• History − History of exposure to risk factors for viral hepatitis such as travel, blood transfusion, sexual contacts, occupation, body piercing, any drug use, or alcohol addiction

• Physical Examination − Mental status examination, Jaundice, pain in the right upper part of the abdomen, check for hepatomegaly, as cited, clinical signs of elevated Intracranial pressure

Investigations include −

• Coagulation studies − Prothrombin time, INR, Complete blood count

• Liver function tests − LFT shows elevated levels of ALT, AST, ALP, Bilirubin

• RBS − May be low

• Serum electrolytes − low serum electrolytes including HCO3, Ca, Mg, Phosphorus

• Renal Function Test − may show elevated creatinine

• Blood group & screen Pregnancy test

• Arterial blood gas − May show hypoxemia

• Raised arterial lactate

Cause-specific tests should also be performed.

Acute Liver Failure Treatment

The treatment of acute liver failure includes −

• Elevate the head to 30 degrees to improve the cerebral perfusion pressure

• The patient should be sedated to prevent the stimuli from rising intracranial pressure

• Avoid hypotension if persists even after fluid replacement then ionotropic support is necessary

• Prevent hypoxemia

• Blood sugar control

• Manito, hypertonic saline through the central line

• Mechanical ventilation, intubation if necessary

• Acute kidney injury if present should also be treated

• Nutritive measures should be done such as avoiding protein intake

• Laxatives are given to aid the excretion

• Fresh frozen plasma is transferred to correct coagulopathies as a liver synthesis of all the coagulation factors is reduced

• N-acetylcysteine is used in case of paracetamol poisoning

• Final mode of treatment is liver transplantation in patients who fails to respond to treatment

Acute Liver Failure Prevention

The risk of occurrence of acute liver failure can be reduced to some extent by the following measures −

• Avoiding intake of medicines more than the prescribed dose by the doctor

• Alcohol should be avoided

• Vaccination for hepatitis B should be taken

• Eating wild mushrooms to be avoided

• Covering with the masks while spraying insecticides, fungicides, paint, and other toxic chemicals

• Healthy balanced diet, regular exercise, and maintaining a proper weight can reduce the occurrence of fatty liver

Conclusion

Acute liver failure is a condition in which the liver has failed to perform its functions. It occurs rapidly over time usually within 26 weeks of illness associated with central nervous system disturbances. It occurs in a patient with no history of pre-existing liver disease. It affects young individuals. Hepatitis virus infection, chronic alcohol intake, an overdose of paracetamol, other drug toxicity, liver cirrhosis, and other liver diseases lead to the acute liver failure.

It presents usually with no specific symptoms and also can present with jaundice and CNS disturbances. The diagnosis should be made earlier to avoid severe complications. The diagnosis can be done based on the history, physical examination, and investigations like liver function tests which show raised liver enzymes, ABG, blood grouping, etc. Once the diagnosis is made the treatment should be as soon as possible as it involves multi-organ systems.

Healthy lifestyle modifications, avoiding alcohol intake and inadvertent use of various drugs and with proper vaccinations the risk of acute liver failure can be reduced.