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Acute liver failure

Last reviewed: 7 Apr 2025
Last updated: 31 Dec 2024

Summary

Definition

History and exam

Key diagnostic factors

  • hepatotoxic drugs
  • chronic alcohol misuse
  • pregnancy
  • jaundice
  • coagulopathy
  • signs of hepatic encephalopathy
Full details

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
  • Wilson disease
  • exposure to hepatotoxins
  • illicit drug use
  • absence of malignancy
Full details

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
  • Wilson disease
  • acetaminophen and antidepressant therapy
  • chronic hepatitis C
  • HIV and hepatitis C coinfection
Full details

Diagnostic tests

1st tests 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
Full details

Tests 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
  • biomarkers
  • liver biopsy
  • CT scan of head
  • CT/MR cholangiography
  • Transcranial Doppler
Full details

Treatment algorithm

ACUTE

all patients

Contributors

Authors

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

TX

Disclosures

SG declares that he has no competing interests.

Acknowledgements

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.

Disclosures

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

CA

Disclosures

Not disclosed.

Muhammad Dawwas, MRCP

Specialist Registrar

Liver Unit

Addenbrooke's Hospital

Cambridge

UK

Disclosures

Not disclosed.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute liver failure guidelines. Am J Gastroenterol. 2023 Jul 1;118(7):1128-53.Full text  Abstract

Lee WM, Squires RH Jr, Nyberg SL, et al. Acute liver failure: summary of a workshop. Hepatology. 2008 Apr;47(4):1401-15.Full text  Abstract

American Association for the Study of Liver Diseases. AASLD position paper: the management of acute liver failure: update 2011. Nov 2011 [internet publication].Full text

Wendon J, Cordoba J, Dhawan A, et al; European Association for the Study of the Liver. EASL clinical practical guidelines on the management of acute (fulminant) liver failure. J Hepatol. 2017 May;66(5):1047-81.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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