Liver failure (including encephalopathy, Fulminant hepatic failure, hepato-renal syndrome)

What is Liver failure?

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Acute hepatic (liver) failure commonly occurs as a result of an acute insult in a patient with chronic liver disease (acute-on-chronic hepatic failure). Fulminant (rapid and severe) hepatic failure (FHF) is when encephalopathy (confusional state) occurs within 8 weeks of the onset of liver damage (of whatever cause) in a previously normal liver.

Statistics on Liver failure?

The exact incidence is unknown, but liver failure complicating cirrhosis is reasonably common, since cirrhosis is a common occurrence. The causes of acute fulminant hepatic failure show considerable geographical variation. with viral hepatitis and paracetamol toxicity being the most common causes. Of the viral causes hepatitis B accounts for most cases.

Risk Factors for Liver failure

Any cause for liver cirrhosis (see cirrhosis) is a potential cause for liver failure. Decompensated cirrhosis may be precipitated by: infection, gastrointestinal bleeds, alcohol, electrolyte imbalances, progression of underlying diseases or liver cancer. Causes of fulminant hepatic failure include: Infections - viral hepatitis, yellow fever, leptospirosis Drugs - eg Paracetamol overdose, anesthetics (halothane) isoniazid (anti-TB agent); Toxins - Amanita mushroom, carbon tetrachloride Vascular - veno-occlusive disease of the liver Others - primary biliary cirrhosis, haematochromatosis, autoimmune hepatitis, alpha 1 antitrypsin deficiency, Wilson's disease, fatty liver of pregnancy, malignancy.

Progression of Liver failure

As the liver failure progresses, the liver's ability to manufacture albumin and clotting factors will be affected - leading to oedema and bleeding problems. Bilirubin excretion is impaired, leading to jaundice. Fever, vomiting, hypotension (low blood pressure) and hypoglycaemia (low blood sugar) are frequently seen. The patient will show varying severity of encephalopathy - from mild confusion to severe drowsiness, and even coma and convulsions (seizures). Other complications include infections, bleeding, and brain oedema which is potentially fatal. The hepato-renal syndrome (HRS) occurs in about 5-10% of patinets with decompensated cirrhosis. It is a type of kidney failure that has a poor prognosis and is thought to be linked to the liver failure.

How is Liver failure Diagnosed?

Blood tests:

Full blood count - may show low Hb due to blood loss;

Urea and electrolytes: abnormal kidney function, potentially renal failure (HRS);

Liver function tests: abnormal, especially low Albumin and high Bilirubin;

Coagulation profile: impaired clotting function;

Blood glucose: may be low;

Cultures - Blood cultures, urine culture looking for infection;

Prognosis of Liver failure

Liver failure is a serious disorder with a poor prognosis in general, although it is difficult to estimate because patients differ in so many characteristics. Before liver transplantation, the mortality rate from fulminant hepatic failure was 70-95%. A few patients survived with only supportive treatment and showed complete recovery without any residual dysfunction. With transplantation, there is now a 65% survival rate. Patient factors are also important.

How is Liver failure Treated?

The patient is usually nursed in ICU. Supportive care is given. Protein intake is restricted, and a purgotives (such as lactulose) may be given to empty the bowel of toxic substances - which can help with encephalopathy. IV infusion of fluids, and glucose may be needed. In addition antibiotics, and blood transfusion will be given if there is any infection or blood loss/clotting abnormality. A nasogastric tube is inserted to avoid aspiration and remove any blood from the stomach. Any complications require further treatment - such as kidney failure requiring dialysis. The patient's temperature, pulse, respiration rate, blood pressure, pupils, and urine output are monitored hourly. The bloods are checked daily for any improvement or worsening. Early liaison with the nearest transplant centre is needed regarding the appropriateness of transfer.

Liver failure References

Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 15th Edition. McGraw-Hill. 2001
Cotran, Kumar, Collins 6th edition. Robbins Pathologic Basis of Disease. WB Saunders Company. 1999.
Haslet C, Chiliers ER, Boon NA, Colledge NR. Principles and Practice of Medicine. Churchill Livingstone 2002.
Hurst JW (Editor-in-chief). Medicine for the practicing physician. 4th edition Appleton and Lange 1996.
Kumar P, Clark M. CLINICAL MEDICINE. WB Saunders 2002
Longmore M, Wilkinson I, Torok E. OXFORD HANDBOOK OF CLINICAL MEDICINE. Oxford Universtiy Press. 2001
McLatchie G and LEaper DJ (editors). Oxford Handbook of Clinical Surgery 2nd Edition. Oxford University Press 2002.
MEDLINE Plus
Raftery AT Churchill's pocketbook of Surgery. Churchill Livingsone 2001.
Tjandra, JJ, Clunie GJ, Thomas, RJS,; Textbook of Surgery, 2nd Ed, Blackwell Science, Asia. 2001.