Acute Liver Failure - Symptoms, Treatment, Causes, Criteria

Acute liver disease is a severe and potentially life-threatening condition when the liver suddenly stops functioning properly. A rapid deterioration of its function and the onset of symptoms within days or weeks characterize it.

It can occur due to liver damage from other underlying medical conditions, such as sepsis or cancer. It is a medical emergency that demands immediate treatment to prevent serious complications, such as brain damage or death.

There are two main types of acute liver failure. Other types or subtypes may be classified based on the underlying cause and severity of the condition. 

1. Hepatic acute liver failure: It is the most common type of acute liver failure, often caused by virus, acetaminophen overdose, or certain medications and toxins.
2. Subfulminant acute liver failure: It is a less common and more severe type of acute liver failure caused by autoimmune liver disease, sepsis, or cancer.

Early signs of acute liver failure frequently resemble those of other disorders, including liver diseases. As a result, it is difficult to diagnose it in the initial stage. However, the following are the signs and symptoms of acute liver failure:

1. Loss of appetite
2. Nausea
3. Vomiting
4. Diarrhoea
5. Musty or sweet breath odour
6. Different types of jaundice
7. Ascites (Swelling in the abdomen)
8. Deranged clotting profile leading to bleeding
9. Hepatic encephalopathy (Reduced brain function)
10. Pain in the upper right abdomen
11. Malaise (general feeling of unwell)
12. Sleepiness

Acute liver failure develops when the cells of the liver get damaged and lose the ability to function. The causes of acute liver failure include:

1. Viral aetiology: The immune system can attack the liver cells in case of Autoimmune Hepatitis, which ultimately can cause injury and inflammation in the liver. If untreated, it can accelerate into acute liver failure.
2. Alcoholic Liver Disease: The liver can damage due to excess consumption of alcohol. Alcoholic liver diseases can cause liver cirrhosis and, ultimately, acute liver failure. 
3. Medicines: Consuming drugs longer than required can lead to drug induced liver injury. 
   1. Acetaminophen overdose: Large doses of acetaminophen or paracetamol can damage the liver and lead to acute liver failure. 
   2. Prescription medications: Consuming medicines like antibiotics, anticonvulsants, and anti-tubercular drugs for a long time, can be damaging to the liver giving rise to acute liver failure.
4. Industrial toxins: Chemicals like carbon tetrachloride, found in refrigerators, is toxic not only to the environment but also to the organs in the body like the liver. It can cause fatty liver and increase toxicity in the liver, which can cause acute liver failure.
5. Poisonous wild mushrooms: Poisonous wild mushrooms like Amanita Phalloides (death cap) have toxins that can lead to acute liver failure. 
6. Budd Chiari Syndrome: Blockage in the veins of the liver caused by Budd Chiari Syndrome results in acute liver failure.
7. Acute Fatty Liver of pregnancy: It is a rare condition in which excess fat gathers in the liver, resulting in damage to the liver. 
8. Septic shock: This overwhelming infection impairs the blood flow to the liver.
9. Cancer: Other types of cancer can spread to the liver and develops liver cancer followed be acute liver failure.

Acute liver failure is a rare syndrome when compared to chronic liver failure. It is essential to consult with a healthcare provider to determine the specific cause and risk factors in an individual case. The risk factors of acute liver failure include:

1. Over 40 years of age
2. Poor nutritional status
3. Improper blood flow to the liver
4. Alcohol
5. Overdose of acetaminophen
6. Viruses like Hepatitis A, B, and E, cytomegalovirus, Epstein-Barr virus, or HSV (herpes simplex virus) 
7. Pre-existing medical conditions, such as hemochromatosis, autoimmune disease, and Wilson disease

There might be no definitive way to prevent acute liver failure. Several lifestyle and dietary changes may help reduce the risk of developing acute liver failure. These include:

1. Eat a healthy and balanced diet: A diet rich in fresh fruits, green leafy vegetables, and whole grains are food good for liver. It can help support overall health and reduce the risk of liver damage.
2. Exercise regularly: Indulging in regular physical activity can help improve overall health and reduce the risk of liver damage.
3. Maintain a healthy weight: Being overweight or obese can increase the risk of liver damage. Therefore, maintaining a healthy weight through diet and exercise can eventually help reduce the risk of liver damage.
4. Avoid smoking: Smoking can increase the risk of liver damage and acute liver failure.
5. Be cautious with medications: Follow the recommended dosage and usage instructions for prescribed drugs to reduce the risk of liver damage.
6. Manage underlying medical conditions: Certain underlying medical conditions, such as diabetes, autoimmune liver disease, and liver hepatitis, can increase the risk of acute liver failure.
7. Practice good hygiene: Good hygiene practices, such as washing hands frequently and avoiding contaminated food and water, can help prevent the spread of viral hepatitis.
8. Get vaccinated against viral hepatitis: Vaccination against viral hepatitis can help prevent infection with hepatitis A, B, and E, which are major causes of acute liver failure.

In the early stage, it would be difficult for the primary care doctor to diagnose acute liver failure based on the symptoms. Thus, the doctor may recommend the following diagnostic tests to confirm the presence of acute liver failure.

1. Blood Tests: Blood tests help the doctor know how well the liver works. 
   1. A prothrombin time test calculates the time taken for the blood to clot. 
   2. A serum bilirubin test measures the level of bilirubin levels in the blood. High levels may indicate a problem in the bile processing by the liver. 
   3. A serum albumin test assesses the albumin level in the blood. Low levels may indicate that the liver is not functioning properly. 
2. Imaging Tests: The doctor may examine the extent of liver damage and determine the cause of the problem using imaging techniques. They may recommend the following tests to look for specific causes of acute liver failure.
   1. Computerised Abdominal Tomography (CT) scanning
   2. Magnetic Resonance Imaging (MRI)
   3. Ultrasound   
3. Liver Biopsy: The surgeon will remove a small piece of liver tissue with the help of a needle and examine it in a lab. Since people diagnosed with acute liver failure are at risk of bleeding excessively during the biopsy, the doctor may perform a Transjugular Liver Biopsy. In this procedure, the doctor makes a small incision on the right side of your neck. A catheter is inserted into the neck vein to retrieve a sample of liver tissue to conduct liver biopsy. 
4. MELD/PELD Score: If an adult with acute liver injury requires a transplant, the MELD (Model for End-stage Liver Disease) score helps determine how quickly they need it. MELD Score consists of total bilirubin, Internal Normalized Ratio (INR) and creatinine. An average MELD score ranges from 6 to 40. The higher the number, the more urgent the liver transplant needs. For children younger than 12, the doctor may use a similar system called PELD (Pediatric End-stage Liver Disease). 

How to prepare for the doctor's consultation?

While preparing for the doctor consultation, the patient must make a prior appointment. Then make a list of the following:

1. Medical history
2. Symptoms experienced
3. All the medications, vitamins or supplements that he/she is taking
4. The patient must inform the doctor about key personal information, including dietary habits

The patient must ask the following questions to the doctor:

1. What is the cause of my acute liver failure?
2. Can the effect be reversed?
3. How can I prevent its progression?
4. What are the risks?
5. What can be the treatment for acute liver failure?
6. Will I need a liver transplant?
7. Can it be treated with medications?

The treatment approach for acute liver failure is selected based on the patient's age, symptoms, the complexity of the condition and the doctor’s opinion. Based on the above-mentioned factors, the doctor may suggest one of the following methods for acute liver failure treatment: 

Acute Liver Failure without surgery

1. Medication: The doctors may prescribe medications to reverse acute liver failure caused by acetaminophen overdose. It can also treat the effects of the toxins caused by mushrooms or other poisons. The doctor may also prescribe medications to:
   1. Relieve pressure caused by excess fluid in the brain 
   2. Prevent severe bleeding
   3. Treat infections
2. Supportive Care: In case of acute liver failure caused by a viral infection, the doctor may treat the patient's symptoms until the virus runs its course. 

Acute Liver Failure with surgery

1. Liver Transplant: When acute liver failure becomes irreversible, the only treatment is a liver transplant. During the procedure, the surgeon replaces the damaged liver with a healthy liver from a donor. Liver transplant cost in India can start from ₹15,00,000.

Acute liver failure can be life-threatening if not treated promptly. Early treatment can improve the chances of a full recovery and reduce the risk of complications. Untreated condition can lead to the following complications:

1. Cerebral Oedema: The excessive build-up of fluid in the brain can cause disorientation, seizures, and mental confusion. 
2. Blood Clots: The liver helps the blood to clot. However, a damaged liver cannot make enough clotting factors, leading to excessive bleeding.
3. Kidney Failure: Acute liver failure can lead to kidney failure by changing its function, especially in the case of an acetaminophen overdose. 
4. Infections: People with end-stage liver disease are more likely to get infections like pneumonia and Urinary Tract Infection.

When to see a doctor?

An early diagnosis can cure the condition. If you experience the following symptoms, then you must visit the doctor as soon as possible:

1. Nausea
2. Diarrhoea
3. Jaundice
4. Vomiting 
5. Loss of appetite

The diet for individuals with acute liver failure should be focused on supporting liver function and providing necessary nutrients. Some general dietary recommendations for acute liver failure may include:

1. Consume enough calories and protein: Individuals with acute liver failure to consume enough calories and protein to support liver function and maintain strength. Protein-rich foods, such as meat, poultry, fish, beans, and nuts, can help support liver function and promote healing.
2. Drink plenty of fluids: Stay hydrated to support liver function and prevent dehydration. Water, broth, and electrolyte solutions can help keep the body hydrated.
3. Eat small, frequent meals: It may be easier for individuals with acute liver failure to tolerate smaller, more frequent meals rather than larger, less frequent meals.
4. Avoid high-fat foods: Foods high in fat can be difficult for the liver to process and may worsen liver damage. It is important to choose low-fat foods and limit the intake of trans and saturated fats.
5. Limit salt intake: A high-salt diet can cause fluid buildup in the body, harming individuals with acute liver failure.
6. Avoid alcohol: It can lead to alcoholic liver diseases as it is toxic and worsen liver damage.