www.turner-white.com Gastroenterology Volume 14, Part 6 1
Acute Liver Failure
Nicholas Agresti, MD, and Christopher O’Brien, MD, AGAF, FRCMI
Acute liver failure (ALF) is the rapid onset of severe liver injury, hepatic encephalopathy, and coagulopathy (international normalized ratio [INR] >1.5)
in a patient without preexisting liver disease.1 The incidence of ALF in the United States is approximately
3000 cases per year, with the majority of ALF cases
caused by drug-induced liver injury (DILI) followed
by viral hepatitis.1–3 Identifying the etiology and
managing the sequelae of liver failure, such as
cerebral edema, encephalopathy, coagulopathy,
hemodynamic instability, renal failure, metabolic
disturbances, and infection, are the mainstays of
4 Prior to the advent of liver transplantation, ALF was almost universally fatal, with a 15%
survival rate. However, with liver transplantation the
1-year survival rate now ranges from 65% to 73%,
and is higher yet with a living related donor transplant.
5–7 The early management of patients should
occur in the intensive care unit (ICU) with transfer to
a liver transplant center as soon as possible.
A patient with ALF will typically present with
laboratory data consistent with acute hepatitis, a
prolonged prothrombin time of 6 seconds or more,
an INR ≥1.5, and a change in mental status. A
focused history and physical examination with at-
tention to ingestion of toxins is important so that
specific therapy can be initiated, as the natural his-
tory of ALF is impacted by its cause (Table 1).
4, 8 An
accurate history is critical, since certain etiologies
of ALF (ie, autoimmune hepatitis, hepatitis B, DILI,
and those of indeterminate cause) have a dismal
survival rate (<25%) without liver transplant.
The initial laboratory studies are directed to
determining the etiology and severity of the liver
disease (Table 2). Blood studies should include a
complete blood count, complete metabolic profile,
arterial blood gas analysis, coagulation profile,
blood type and screen, and diagnostic tests to rule
out specific etiologies of ALF.
The initial physical exam should include a mental
status exam with documentation of grade of encephalopathy (Table 3) and a search for findings
consistent with preexisting, chronic liver disease,
such as bitemporal wasting, parotid gland enlargement, spider angiomata, gynecomastia, splenomegaly, and testicular atrophy. Although ascites is
typically seen in chronic liver disease, it can present in ALF with etiologies such as veno-occlusive
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