Last reviewed:September 2019
Last updated:June  2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • hepatotoxic medication
  • jaundice
  • signs of hepatic encephalopathy

Other diagnostic factors

  • absence of hx of chronic liver disease
  • abdominal pain
  • nausea
  • vomiting
  • malaise
  • signs of cerebral oedema
  • abdominal or right upper quadrant tenderness
  • hepatomegaly
  • absence of splenomegaly
  • absence of spider angiomata
  • absence of palmar erythema
  • absence of ascites
  • depression or suicidal ideation
  • exposure to hepatotoxins
  • illicit drug abuse and high-risk behaviours

Risk factors

  • chronic alcohol abuse
  • poor nutritional status
  • female sex
  • age >40 years
  • pregnancy
  • chronic hepatitis B
  • chronic pain and narcotic use
  • complementary and alternative medicine hepatotoxicity
  • paracetamol and antidepressant therapy
  • chronic hepatitis C
  • HIV and hepatitis C co-infection

Diagnostic investigations

1st investigations to order

  • liver function tests
  • prothrombin time/INR
  • basic metabolic panel
  • FBC
  • blood type and screen
  • arterial blood gas
  • arterial blood lactate
  • paracetamol level
  • urine toxicology screen
  • factor V level
  • viral hepatitis serologies
  • autoimmune hepatitis markers
  • serum ceruloplasmin
  • pregnancy test
  • chest x-ray
  • abdominal ultrasound with Doppler
Full details

Investigations to consider

  • viral hepatitis PCR studies
  • serum copper
  • 24-hour urinary copper excretion
  • slit-lamp ophthalmological examination
  • arterial ammonia
  • HIV test
  • urinalysis and urine sodium
  • surveillance cultures
  • Coombs test
  • liver biopsy
  • CT scan of head
Full details

Treatment algorithm


Stevan A. Gonzalez

Clinical Assistant Professor

Department of Internal Medicine

Texas A&M College of Medicine

Medical Director of Liver Transplantation

Annette C. and Harold C. Simmons Transplant Institute

Baylor All Saints Medical Center

Fort Worth



SAG declares that he has no competing interests.

Dr Stevan Gonzalez would like to gratefully acknowledge the late Dr Emmet B. Keeffe who previously co-contributed to this monograph; an esteemed colleague, friend, and mentor. EBK declared that he had no competing interests.

Peer reviewersVIEW ALL

Director of Acute Liver Failure Program

California Pacific Medical Center Liver Transplant Program

San Francisco



Not disclosed.

Specialist Registrar

Liver Unit

Addenbrooke's Hospital




Not disclosed.

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