Introduction
Acute liver failure is a medical emergency that occurs when your liver rapidly loses its ability to function. Most often, liver failure develops slowly over the course of years, usually due to long-term alcohol use or infection with the hepatitis virus. But acute liver failure can develop in a matter of days.
Many cases of acute liver failure follow an acetaminophen (Tylenol) overdose. Less commonly, acute liver failure results from a viral infection, poisoning or an underlying condition affecting blood flow in your liver.
The first goal in treating acute liver failure is to manage the problems caused by a failing liver, such as the buildup of toxins in your bloodstream. Then, your liver may be able to heal on its own, or you may need a liver transplant to make a recovery.
Signs and symptoms
Before your liver fails, you may have signs and symptoms that suggest liver disease, such as:
- A yellowing of your skin and eyeballs (jaundice)
- Tenderness in the upper right area of your abdomen
As your condition worsens, a condition called encephalopathy may develop. Encephalopathy refers to brain and nervous system damage that results from your liver’s inability to metabolize toxins into harmless substances. These toxins build up in your body, causing signs and symptoms.
Signs and symptoms of encephalopathy include changes in mental state, behavior and personality, such as the following:
- Confusion, forgetfulness, disorientation and delirium
- Sleepiness or decreased responsiveness
- Muscle tremors and stiffness
- Uncontrollable or dysfunctional movement, such as difficulty with handwriting
- Mood changes or agitation
In severe cases, people with acute liver failure lose consciousness and become comatose.
People with acute liver failure also have bleeding problems because a failing liver can’t produce sufficient amounts of substances that help blood clot. So, even minor cuts on your skin can cause severe bleeding.
Causes
Your liver is a large, multilobed organ located on the right-hand side of your abdomen.
Several common functions of your liver include:
- Filtering toxins, bacteria and waste products from your blood
- Producing many substances, including proteins that help your blood clot (clotting factors) and bile, which breaks down fats
- Storing vitamins, iron, sugar and cholesterol
When your liver fails, its ability to perform any of these functions is hampered.
Causes of acute liver failure include:
- Drugs. Acetaminophen (Tylenol, others) overdose is the most common cause of acute liver failure. Many other medications, including herbal supplements such as kava extract, can cause drug reactions that lead to liver failure; however, these types of reactions are rare.Using recreational drugs like Ecstasy and cocaine also can lead to acute liver failure.
- Viruses. Hepatitis A and hepatitis B are the viruses that most often cause acute liver failure in the U.S., while hepatitis E is a more common cause in countries where the virus is endemic, especially among pregnant women.Other viruses associated with acute liver failure include cytomegalovirus, herpes simplex virus, Epstein-Barr virus, hemorrhagic fever viruses and paramyxovirus.
- Toxins. Toxins from bacteria and industrial chemicals, such as carbon tetrachloride, can damage your liver. The wild mushroom Amanita phalloides, which is sometimes mistaken for other edible species, is poisonous and causes acute liver failure.
- Autoimmune disease. Autoimmune hepatitis is a disease in which your immune system attacks liver cells, causing inflammation and injury.
- Vascular disease. Conditions that cause blockages to form in the veins of the liver can cause acute liver failure. These include portal vein thrombosis, Budd-Chiari syndrome and veno-occlusive disease.
- Metabolic disease. Rare metabolic diseases, such as Wilson’s disease, acute fatty liver of pregnancy and Reye’s syndrome infrequently cause acute liver failure.
- Cancer. Malignant tumors that grow in your liver or cancer that spreads to your liver from another organ can cause your liver to fail.
In about 15 percent of cases of acute liver failure, there’s no identifiable cause.
Risk factors
Taking more acetaminophen than the recommended daily dosage increases your risk of developing acute liver failure, especially if you have pre-existing liver disease.
When to seek medical advice
Acute liver failure can develop quickly in an otherwise healthy person, and it is life-threatening. If you or someone you know suddenly develops a yellowing of the eyes or skin, tenderness in the upper abdomen or any unusual changes in mental state, personality or behavior, seek medical attention right away.
Screening and diagnosis
If your doctor suspects that you might have acute liver failure, you’ll be examined for signs and symptoms of liver disease, such as a yellowing of your skin and eyeballs (jaundice) and a swollen and tender abdomen.
Your doctor will ask you or your family about the medications that you take, including any herbal supplements and whether you use recreational drugs, tobacco or alcohol. Your doctor may also ask whether you’ve eaten mushrooms recently. You’ll likely discuss whether you’re at risk of viral hepatitis, which can be acquired through sexual activity, tattoos or body piercings and transfusions.
Diagnostic tests are the next step. These include:
- Blood tests. A series of blood tests is performed to see how well your liver is functioning. An important blood test, called the prothrombin time test, measures how long it takes for your blood to clot. If you have acute liver failure, your blood doesn’t clot as quickly as it should.
- Imaging tests. An ultrasound, a computerized tomography (CT) scan and a magnetic resonance imaging (MRI) scan are diagnostic tools that help your doctor visualize blood vessels and other structures in your liver and detect the presence of cancer. A CT scan can also be used to determine whether there’s swelling occurring in your brain (cerebral edema).
- Electroencephalogram (EEG). This test measures electrical activity in your brain. Flat metal disks (electrodes) are attached to your head with a sticky paste. The electrodes have wires that connect to a recording machine, which converts the electrical signals into a series of wavy lines on paper. This test doesn’t cause any discomfort. EEG results are often abnormal if you have acute liver failure because toxins that a failing liver is unable to clear from your bloodstream can affect your brain.
- Liver biopsy. Examining a sample of liver tissue (biopsy) can help your doctor determine why your liver is failing. During a transjugular liver biopsy, your doctor makes a tiny insertion on the right side of your neck and passes a thin tube (catheter) into a large vein in your neck, through your heart and down into a vein exiting your liver. Your doctor then inserts a needle down through the catheter and retrieves a sample of liver tissue.A transjugular liver biopsy is more difficult to perform than is a percutaneous liver biopsy, in which your doctor obtains a liver tissue sample through a small incision in your abdomen. However, a percutaneous liver biopsy isn’t usually performed in these cases because people with acute liver failure often have bleeding disorders. A percutaneous biopsy increases the risk of severe bleeding.
Complications
Complications from acute liver failure are common. They may include:
- Cerebral edema. Cerebral edema refers to an excessive amount of fluid collecting in your brain. Excessive fluid causes pressure to build in your brain, which can displace brain tissue outside of the compartment it normally occupies (herniation). Cerebral edema can also deprive your brain of oxygen. It’s not certain why acute liver failure causes cerebral edema.
- Bleeding disorders. A failing liver isn’t able to produce sufficient amounts of clotting factors, which helps blood clot. Bleeding from ulcers in the gastrointestinal tract or other locations is difficult to control because it doesn’t clot quickly.
- Infection. People with acute liver failure are at an increased risk of developing a variety of infections, particularly in the blood and in the respiratory and urinary tracts.
- Pulmonary edema. A buildup of fluid in your lungs (pulmonary edema) can cause breathing difficulties.
- Kidney failure. Kidney failure often occurs following liver failure, especially in cases of acetaminophen overdose, which damages both your liver and your kidneys.
Acute liver failure can be fatal, so promptly identifying and treating complications is essential.
Treatment
People with acute liver failure are usually admitted to an intensive care unit in a hospital for continual monitoring. Depending on the cause of acute liver failure and your signs and symptoms, treatment may include:
- Reversing poisoning with an antidote. Acute liver failure caused by acetaminophen overdose or mushroom poisoning is treated with drugs that can reverse the effects of the toxin.
- Relieving cerebral edema. Acute liver failure can lead to brain swelling (cerebral edema), which increases pressure on your brain. If you have severe cerebral edema, your doctor will give you medications through a vein in your arm to help reduce the fluid buildup in your brain.
- Screening for infections. Screening your blood, urine and sputum for signs of infection is important because people with acute liver failure are especially susceptible to developing infections. If your doctor suspects that you have an infection, you’ll receive antibiotics or antifungal medications.
- Preventing severe bleeding. People with acute liver failure often develop bleeding ulcers in the gastrointestinal tract. Your doctor will give you medications to help abate the bleeding. If you’re losing a lot of blood, you’ll need blood transfusions.
Additional treatments may include fluid, electrolyte and glucose supplementation.
Liver transplantation
Your liver is one of the few organs in your body that has the ability to regenerate — meaning that if part of your liver is removed or damaged, your liver can grow back to approximately its original size. But sometimes, the liver damage may be so severe that your liver can’t regenerate. Liver transplantation is necessary in such cases.
Liver transplantation usually involves surgically placing a whole liver or part of a liver from a deceased donor into a recipient. Living-donor transplants are another type of transplant in which part of a living donor’s liver is given; both partial livers regenerate after being transplanted.
Liver transplantation is a lengthy surgery and complications, such as infection, bleeding and even death are possible. In some cases, the new liver may be rejected by your body.
The wait for a liver donation can be long, so researchers are working on alternatives to donated livers, such as artificial livers and machines that can perform liver functions. Currently, their use is mostly limited to clinical trials.
Prevention
Here are a few ideas to help you reduce your risk of developing acute liver failure:
- Follow dosing instructions. If you take acetaminophen or other medications, be sure to check the package insert for instructions on the recommended dosage. If you use tobacco products or drink regularly, check with your doctor before taking any drugs.
- Don’t use recreational drugs. They’re often addictive and can cause a multitude of health problems, including liver failure.
- Stay up-to-date on your vaccinations. Make sure that you’ve received all recommended vaccinations, including the hepatitis B series. If you’re traveling abroad for an extended period of time, ask your doctor whether you should receive the hepatitis A series.
- Plan for pregnancy. Several rare disorders of pregnancy can cause acute liver failure, so be sure to see your doctor for regular prenatal care. If you’re living in an area where hepatitis E is endemic, make sure that you have access to safe drinking water. If you contract hepatitis E while you’re pregnant, you’re at risk of developing acute liver failure.