Acute liver failure (ALF), also known as fulminant hepatic failure, refers to sudden severe liver dysfunction from injury without underlying chronic liver disease (CLD), although sometimes it presents as decompensation of unknown chronic liver disease.
Acute liver failure is rare, with <1 case per 100,000 in the developed world 5.
Symptoms and signs of hepatic encephalopathy and/or coagulopathy is the most common presentation.
There are many causes for acute liver failure 1,3,4:
- viral infection, hepatitis B is probably the most common 5,6
- idiopathic (15%), i.e. cause unknown
- drug toxicity, e.g. acetaminophen toxicity, chemotherapeutic agents
- toxin exposure, e.g. toxic mushrooms, carbon tetrachloride (industrial chemical), aflatoxin 7
- metabolic disease, e.g. Wilson disease, Reye disease, acute fatty liver of pregnancy, HELLP syndrome
- vascular causes, e.g. Budd-Chiari syndrome, right heart failure, shock
- autoimmune hepatitis
General features may include:
Features of cirrhosis (i.e. splenomegaly, enlarged collateral vessels, liver surface nodularity) are present in 20-30% of patients with acute liver failure (ALF), although it should be stressed that patients with ALF do not have cirrhosis 3.
- early: decreased liver echogenicity (cf. right kidney)
- late: the liver becomes heterogeneously echogenic 1
Vascular assessment with Doppler ultrasound is useful in determining the patency of the hepatic artery, hepatic vein, and portal vein. A diagnosis of Budd-Chiari syndrome, ischemic hepatitis, and portal vein thrombosis may be confirmed or excluded during workup8.
CT may demonstrate the general imaging features along with heterogeneous enhancement on portal venous phase imaging 3.
Treatment and prognosis
Mortality is high in acute liver failure at ~50% (range 30-70%) with orthotopic liver transplant considered the definitive treatment 3,4. The goals of management include identification of reversible causes of acute liver failure, provide organ support to maximize the probability of recovery as well as to perform risk stratification and identify patients for consideration of early liver transplantation, as they may not survive supportive care 8. Consideration for transfer to a center with expertise in liver transplantation may be appropriate 8.
- 1. Diagnostic and Interventional Radiology in Liver Transplantation (Medical Radiology). Springer. ISBN:3642629504. Read it at Google Books - Find it at Amazon
- 2. Mirvis SE, Soto JA, Shanmuganathan K et-al. Problem Solving in Emergency Radiology: Expert Consult - Online. Saunders. ISBN:B00N04AZQC. Read it at Google Books - Find it at Amazon
- 3. Romero M, Palmer SL, Kahn JA et-al. Imaging appearance in acute liver failure: correlation with clinical and pathology findings. Dig. Dis. Sci. 2014;59 (8): 1987-95. doi:10.1007/s10620-014-3106-6 - Pubmed citation
- 4. Gershwin ME, Vierling JM, Manns MP. Liver Immunology. Springer International Publishing. ISBN:B00GRNSQR8. Read it at Google Books - Find it at Amazon
- 5. Bernal W, Wendon J. Acute liver failure. N. Engl. J. Med. 2013;369 (26): 2525-34. doi:10.1056/NEJMra1208937 - Pubmed citation
- 6. Gotthardt D, Riediger C, Weiss KH et-al. Fulminant hepatic failure: etiology and indications for liver transplantation. Nephrol. Dial. Transplant. 2007;22 Suppl 8 (suppl 8): viii5-viii8. doi:10.1093/ndt/gfm650 - Pubmed citation
- 7. Drug-Induced Liver Disease, Third Edition. Academic Press. ISBN:0123878179. Read it at Google Books - Find it at Amazon
- 8. S. Warrillow, R. Bellomo. Intensive Care Management of Severe Acute Liver Failure. (2020) doi:10.1007/978-3-319-13761-2_30