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Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis

Eric Goldberg, MD
Sanjiv Chopra, MD, MACP
Section Editor
Robert S Brown, Jr, MD, MPH
Deputy Editor
Kristen M Robson, MD, MBA, FACG


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 [1]. 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".)

The discussion that follows is consistent with the 2011 The American Association for the Study of Liver Diseases guideline for the management of acute liver failure [2].


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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Literature review current through: Nov 2017. | This topic last updated: Aug 12, 2015.
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