Rare disease associated with jaundice, coagulopathy, and hepatic encephalopathy.
The aetiology and the interval from onset of jaundice to the development of encephalopathy have a significant impact on prognosis.
Aetiology is established by history, serological assays, and exclusion of alternative causes, including acute presentations of chronic liver diseases.
Treatment involves ICU monitoring, specific therapies based on aetiology, and management of known complications.
All patients should be considered for possible liver transplantation.
Prognostic models may be used to assess the probability of spontaneous recovery and are instrumental in selection of patients who should potentially undergo liver transplantation.
Acute liver failure (ALF) is a rare syndrome defined by a rapid decline in hepatic function characterised by jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy in patients with no evidence of prior liver disease. The interval from the onset of jaundice to the development of encephalopathy occurs within 24 to 26 weeks and may further classify ALF into categories based on hyperacute, acute, or subacute presentations. Although clinical jaundice is considered a defining feature of ALF, it may not always be present, particularly in hyperacute presentations. The term acute liver failure is preferred over fulminant hepatic failure or acute hepatic necrosis, although these terms have been used historically to classify hepatic failure.
History and exam
- absence of hx of chronic liver disease
- abdominal pain
- signs of cerebral oedema
- abdominal or right upper quadrant tenderness
- 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
- liver function tests
- prothrombin time/INR
- basic metabolic panel
- 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
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
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.
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