Acute liver failure

Last reviewed: 22 Aug 2023
Last updated: 10 Jan 2023



History and exam

Key diagnostic factors

  • hepatotoxic medication
  • chronic alcohol misuse
  • pregnancy
  • jaundice
  • signs of hepatic encephalopathy
More key diagnostic factors

Other diagnostic factors

  • absence of history of chronic liver disease
  • abdominal pain
  • nausea
  • vomiting
  • malaise
  • signs of cerebral edema
  • 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 misuse and high-risk behaviors
  • absence of malignancy
Other diagnostic factors

Risk factors

  • chronic alcohol misuse
  • poor nutritional status or fasting
  • female sex
  • age >40 years
  • pregnancy
  • chronic hepatitis B
  • chronic pain and narcotic use
  • herbal and dietary supplement hepatotoxicity
  • acetaminophen and antidepressant therapy
  • chronic hepatitis C
  • HIV and hepatitis C coinfection
More risk factors

Diagnostic investigations

1st investigations to order

  • liver function tests
  • prothrombin time/INR
  • basic metabolic panel
  • CBC
  • blood type and screen
  • serum amylase and lipase
  • arterial blood gas
  • arterial blood lactate
  • acetaminophen level
  • urine toxicology screen
  • viral hepatitis serologies
  • autoimmune hepatitis markers
  • pregnancy test
  • chest x-ray
  • abdominal ultrasound with Doppler
More 1st investigations to order

Investigations to consider

  • factor V level
  • viral hepatitis polymerase chain reaction (PCR) studies
  • serum ceruloplasmin
  • serum copper
  • 24-hour urinary copper excretion
  • slit-lamp ophthalmologic examination
  • arterial ammonia
  • HIV test
  • urinalysis and urine sodium
  • surveillance cultures
  • Coombs test
  • liver biopsy
  • CT scan of head
  • CT/MR cholangiography
  • Transcranial Doppler
More investigations to consider

Treatment algorithm


all patients



Stevan A. Gonzalez, MD, MS
Stevan A. Gonzalez

Associate Professor

Department of Internal Medicine

TCU and UNTHSC School of Medicine

Medical Director of Liver Transplantation

Annette C. and Harold C. Simmons Transplant Institute

Baylor All Saints Medical Center

Fort Worth



SG has received honoraria from Mallinckrodt Pharmaceuticals for consulting work and from Salix Pharmaceuticals for speaker’s bureau and consulting work. SG has previously received honoraria from Intercept Pharmaceuticals for advisory activities.


Dr Stevan Gonzalez would like to gratefully acknowledge the late Dr Emmet B. Keeffe who previously co-contributed to this topic; an esteemed colleague, friend, and mentor.


EBK declared that he had no competing interests.

Peer reviewers

Timothy J. Davern, MD

Director of Acute Liver Failure Program

California Pacific Medical Center Liver Transplant Program

San Francisco



Not disclosed.

Muhammad Dawwas, MRCP

Specialist Registrar

Liver Unit

Addenbrooke's Hospital




Not disclosed.

  • Differentials

    • Severe acute hepatitis
    • Cholestasis
    • Hemolysis
    More Differentials
  • Guidelines

    • Acute-on-chronic liver failure clinical guidelines
    • AASLD practice guidance on drug, herbal and dietary supplement-induced liver injury
    More Guidelines
  • Patient leaflets

    Acute liver failure

    Hepatitis B: should I have the vaccine?

    More Patient leaflets
  • Videos

    Tracheal intubation: animated demonstration

    Bag-valve-mask ventilation: animated demonstration

    More videos
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer