Liver Failure
Definition
Liver failure: Severe loss of liver function due to extensive hepatocellular damage.
Types:
o Acute Liver Failure (ALF): Rapid onset of liver dysfunction in a patient without pre-
existing liver disease, typically within days to weeks.
o Chronic Liver Failure (CLF): Progressive decline in liver function over months to
years, often due to cirrhosis.
Etiology
Acute Liver Failure
Drug-induced liver injury (DILI): Most common in Europe/US (e.g., paracetamol overdose).
Viral hepatitis: Hepatitis A, B, E (common worldwide).
Other causes: Autoimmune hepatitis, Wilson’s disease, ischemic injury, toxins (mushrooms,
chemicals).
Chronic Liver Failure
Alcoholic liver disease.
Chronic viral hepatitis (B, C).
Non-alcoholic fatty liver disease (NAFLD).
Genetic/metabolic disorders: Hemochromatosis, Wilson’s disease.
Autoimmune hepatitis.
Primary biliary cholangitis, primary sclerosing cholangitis.
Pathophysiology
Loss of hepatocyte function → impaired metabolism of bilirubin, ammonia, drugs, hormones.
Coagulopathy: Reduced synthesis of clotting factors.
Portal hypertension: Increased resistance to portal blood flow → varices, ascites.
Hepatic encephalopathy: Accumulation of ammonia and neurotoxins → altered mental
status.
Multi-organ involvement: Renal failure (hepatorenal syndrome), circulatory collapse.
Clinical Features
Acute Liver Failure
Jaundice (rapid onset).
Coagulopathy (INR ≥ 1.5).
Hepatic encephalopathy (confusion, coma).
Nausea, vomiting, abdominal pain.
Cerebral edema (raised intracranial pressure).
Chronic Liver Failure
Fatigue, anorexia, weight loss.
Jaundice, pruritus.
Ascites, edema.
Variceal bleeding (hematemesis, melena).
Muscle wasting.
Hepatic encephalopathy (late stage).
Investigations
Blood tests:
o Liver function tests (ALT, AST, ALP, bilirubin).
o Coagulation profile (PT/INR).
o Serum ammonia.
o Viral serology (HBsAg, anti-HCV).
Imaging:
o Ultrasound (ascites, cirrhosis, masses).
o CT/MRI (structural abnormalities).
Biopsy: For etiology in chronic disease.
Special tests: Ceruloplasmin (Wilson’s), iron studies (hemochromatosis).
Management
Acute Liver Failure
Supportive care: ICU monitoring, fluid/electrolyte balance.
Specific therapy:
o N-acetylcysteine for paracetamol overdose.
o Antivirals for hepatitis B.
o Chelation for Wilson’s disease.
Prevent complications:
o Mannitol for cerebral edema.
o Lactulose for encephalopathy.
o Vitamin K, FFP for coagulopathy.
Definitive: Liver transplantation if unresponsive.
Chronic Liver Failure
Treat underlying cause:
o Abstinence from alcohol.
o Antivirals for hepatitis B/C.
o Lifestyle modification for NAFLD.
Manage complications:
o Diuretics for ascites.
o Endoscopic banding for varices.
o Lactulose/rifaximin for encephalopathy.
Nutrition: High-protein diet unless encephalopathy severe.
Definitive: Liver transplantation in end-stage disease.
Complications
Hepatic encephalopathy.
Cerebral edema (acute).
Variceal bleeding.
Ascites, spontaneous bacterial peritonitis.
Hepatorenal syndrome.
Coagulopathy → bleeding tendency.
Increased risk of infections.
Quick Comparison Table
Chronic Liver Failure
Feature Acute Liver Failure (ALF)
(CLF)
Onset Days to weeks Months to years
Paracetamol overdose, viral Alcohol, chronic
Common causes
hepatitis hepatitis, NAFLD
Jaundice, encephalopathy, Ascites, varices, muscle
Key signs
coagulopathy wasting
Cerebral edema, multi-organ Portal hypertension,
Complications
failure cirrhosis
Chronic Liver Failure
Feature Acute Liver Failure (ALF)
(CLF)
Supportive, transplant if Manage cause, transplant
Treatment
needed if end-stage
Prognosis
Acute liver failure: High mortality without transplant; survival depends on cause and rapid
intervention.
Chronic liver failure: Progressive, irreversible; prognosis depends on stage (Child-Pugh,
MELD score).
