Hepatic failure is defined as the occurrence of signs or symptoms of hepatic

encephalopathy in a person with severe acute or chronic liver disease.

Liverfailure


• Acute liver failure is an uncommon syndrome in which hepatic encephalopathy,

characterized by mental changes progressing from confusion to stupor and coma, results

from a sudden severe impairment of hepatic function.

• Chronic liver failure develops when the functional capacity of the liver can no longer

maintain normal physiological conditions.

• The term 'hepatic decompensation' or 'decompensated liver disease' is often used when

a chronic liver failure occurs.

Causes

• Acute Liver Failure

Any cause of liver damage can produce acute liver failure, provided it is sufficiently

severe, hepatitis is the most common cause worldwide.

Paracetamol toxicity is the most frequent cause in the UK.

Acute liver failure occurs occasionally with other drugs, or from Amanita phalloides

(mushroom) poisoning, in pregnancy, in Wilson's disease, following shock and,

rarely, in extensive malignant the disease of the liver.

• Chronic Liver Failure

The most common cause is cirrhosis, which is usually the result of chronic liver injury

occurring over many years.

Chronic liver failure may occur as a consequence of insidious destruction of

hepatocytes or acute on chronic an injury such as may occur in viral or alcoholic

hepatitis.

Also may supervene when certain clinical situations lead to increased metabolic

demands on the liver, e.g. infection or gastrointestinal hemorrhage.

Clinical Features of Liver Failure

• The first signs of hepatic encephalopathy can be a subtle and nonspecific change in sleep

patterns, change in personality, irritability, and mental dullness.

• Thereafter, confusion, disorientation, stupor, and eventually coma supervene.

• Physical findings include asterixis and flapping tremors of the body and tongue.

• Fetor hepatitis refers to the slightly sweet, ammoniacal odor that is common in patients

with liver failure, particularly if there is portal-venous shunting of blood around the liver.

• Other causes of coma and confusion should be excluded, mainly electrolyte imbalances,

sedative use, and renal or respiratory failure.

• Cerebral edema can produce increased intracranial pressure causing unequal or

abnormally reacting pupils, fixed pupils, hypertensive episodes, bradycardia,

hyperventilation, profuse sweating, local or general myoclonus, focal fits, or decerebrate

posturing.

• More general symptoms include weakness, nausea, and vomiting.

• Right hypochondrial discomfort is an occasional feature.

• A helpful measure of hepatic encephalopathy is a careful mental status examination and

use of the trail making test, which consists of a series of 20 numbered circles that the

the patient is asked to connect as rapidly as possible using a pencil.

• The normal range for the connect-the-dot test is 15 to 30s; it is considerably delayed in

patients with early hepatic encephalopathy.

• Other tests include drawing abstract objects or comparison of a signature to previous

examples.

• Other signs of advanced liver disease include umbilical hernia from ascites, prominent

veins over the abdomen, and caput medusa, which consists of collateral veins seen

radiating from the umbilicus and resulting from the recanalization of the umbilical vein

• Widened pulse pressure and signs of a hyperdynamic circulation can occur in patients

with cirrhosis as a result of fluid and sodium retention increased cardiac output, and

reduced peripheral resistance.

Features of Chronic Liver Failure

• Prolonged prothrombin time

• Low albumin

• Jaundice

• Portal hypertension

• Variceal bleeding

• Hepatic encephalopathy

• Ascites

• Spontaneous bacterial peritonitis

• Hepatorenal failure

Differential Diagnoses, Investigations, Treatment, and Complications of

Liver Failure

Differential Diagnosis

• Hypoglycemia

• Delirium tremens

• Drug or alcohol intoxication

• Subdural hematoma

• Wernicke's encephalopathy

• Primary psychiatric disorders

• Neurological Wilson's disease

Investigations

• All the specific investigations for liver failure may not be available in the dispensaries

and health centers and patients should be referred to hospitals.

• Investigations are used to determine the cause of the liver failure and the prognosis

• Hepatitis B core IgM antibody is the best screening test for acute hepatitis B infection

• HBsAg may be negative

• Full blood picture

Anaemia Normocromic Normocytic

Low white blood count

Reduced platelets due to hypersplenism

Raised ESR

• Liver function test

Raised AST, ALT

Reduced Albumin,

Prolonged Prothrombin Time

Treatment

• No specific management can be offered at the dispensary and health center.

• Resuscitate the patient if there is a need, then refer him/her.

Acute Liver Failure

• Conservative treatment aims to maintain life in the hope that hepatic regeneration will

occur.

Monitor vital signs input and output.

• N-acetylcysteine therapy may improve outcomes, particularly in patients with acute liver

failure due to paracetamol poisoning.

• Liver transplantation is an increasingly important treatment option for acute liver failure

but this is limited to specialized hospitals mostly in the developed countries.

Encephalopathy and cerebral edema

Complications of Acute Liver Failure

• Hypoglycemia

• Metabolic acidosis

• Infection (bacterial, fungal)

• Renal failure

• Multi-organ failure (hypotension and respiratory failure)                            

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