Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis
- Eric Goldberg, MD
Eric Goldberg, MD
- Associate Professor of Medicine
- University of Maryland School of Medicine
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology and Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
- Section Editor
- Robert S Brown, Jr, MD, MPH
Robert S Brown, Jr, MD, MPH
- Section Editor — Liver Transplantation
- Vice Chair, Transitions of Care, Department of Medicine
- Interim Chief, Division of Gastroenterology and Hepatology
- Weill Cornell Medical College
- Professor of Clinical Medicine, Columbia University College of Physicians & Surgeons
Acute liver failure is characterized by acute liver injury, hepatic encephalopathy, and an elevated prothrombin time/international normalized ratio (INR). It has also been referred to as fulminant hepatic failure, acute hepatic necrosis, fulminant hepatic necrosis, and fulminant hepatitis. Untreated, the prognosis is poor, so timely recognition and management of patients with acute liver failure is crucial . Whenever possible, patients with acute liver failure should be managed in an intensive care unit at a facility capable of performing liver transplantation.
This topic will review the etiology, clinical manifestations, and diagnosis of acute liver failure in adults. The prognosis and management of patients with acute liver failure is discussed separately. (See "Acute liver failure in adults: Management and prognosis".)
Acute liver failure refers to the development of severe acute liver injury with encephalopathy and impaired synthetic function (INR of ≥1.5) in a patient without cirrhosis or preexisting liver disease [2,3]. While the time course that differentiates acute liver failure from chronic liver failure varies between reports, a commonly used cutoff is an illness duration of <26 weeks.
Acute liver failure may also be diagnosed in patients with previously undiagnosed Wilson disease, vertically acquired hepatitis B virus, or autoimmune hepatitis, in whom underlying cirrhosis may be present, provided the disease has been recognized for <26 weeks. On the other hand, patients with acute severe alcoholic hepatitis, even if recognized for <26 weeks, are considered to have acute-on-chronic liver failure since most have a long history of heavy drinking. The approach to such patients is discussed elsewhere. (See "Clinical manifestations and diagnosis of alcoholic fatty liver disease and alcoholic cirrhosis" and "Prognosis and management of alcoholic fatty liver disease and alcoholic cirrhosis".)
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- Viral hepatitis
- Acetaminophen and other hepatotoxins
- Idiosyncratic drug reactions
- CLINICAL MANIFESTATIONS
- Physical examination findings
- - Neurologic examination
- - Other physical examination findings
- Laboratory test abnormalities
- - Laboratory findings associated with specific diagnoses
- Imaging and other studies
- Diagnosing acute liver failure
- Determining the cause of acute liver failure
- - Timing of the evaluation
- - History
- - Physical examination
- - Laboratory evaluation
- - Imaging studies
- - Liver biopsy
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS