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Liver Failure

Hepatic Insufficiency

Liver failure is a condition in which the liver fails to perform its normal function. It may be acute or chronic.


Presentation

Some of the early symptoms of liver failure are also common with other ailments [7]. This is why early diagnosis of liver failure is hard. Some of these early symptoms include diarrhea, fatigue, loss of appetite and nausea.

As the disease progresses, other serious symptoms will set in. At this point, urgent medical care is needed. Some of these symptoms are jaundice, easy or excessive bleeding, swollen abdomen, confusion (hepatic encephalopathy), sleepiness and coma.

Easy Bruising
  • Kidney disease or failure Easy bruising and severe bleeding. This happens when the liver stops making proteins that are needed for your blood to clot. Type 2 diabetes.[hopkinsmedicine.org]
  • […] symptoms may include: Fluid buildup of the legs (edema) and in the abdomen ( ascites ) Yellow color in the skin, mucous membranes, or eyes ( jaundice ) Redness on the palms of the hands In men, impotence, shrinking of the testicles, and breast swelling Easy[medlineplus.gov]
  • When symptoms do appear, they include, bleeding or easy bruising, swelling, fatigue, and a yellow coloring to the skin and whites of the eyes.[emedicinehealth.com]
  • They can include: Bleeding in the gut Easy bruising Fatigue Jaundice (yellow skin) Increased sensitivity to alcohol and drugs, both medical and recreational (because the liver cannot process them Itching Liver cancer Swelling of the legs ankles, or abdomen[drinkaware.co.uk]
Hypothermia
  • Future possible therapeutic approaches include N-acetylcysteine, hypothermia, liver assist devices, and hepatocyte transplantation. Advances in stem cell research may allow provision of cells for bioartificial liver support.[ncbi.nlm.nih.gov]
  • Induced hypothermia is also an experimental therapy but is not yet routinely done (has risks of coagulopathy, infection risk, and arrhythmias).[errolozdalga.com]
  • Therapeutic hypothermia in the management of acute liver failure. Neurochem Int 2012 ;60: 723 - 735 36. Desjardins P, Du T, Jiang W, Peng L, Butterworth R.[nejm.org]
  • A possible treatment that is being assessed is hypothermia. [ 7 ] Acute kidney injury may require haemodialysis or continuous arteriovenous haemofiltration, as the former can drop blood pressure to a dangerous level.[patient.info]
Clay-Colored Stool
  • As liver function is gradually lost, some or all of these signs of liver disease may appear: Jaundice (yellow coloring of the skin and eyes) Itching Dark, tea-colored urine Clay-colored stools Weight loss and muscle wasting Tendency to bruise and bleed[emoryhealthcare.org]
  • […] ascites ) Yellow color in the skin, mucous membranes, or eyes ( jaundice ) Redness on the palms of the hands In men, impotence, shrinking of the testicles, and breast swelling Easy bruising and abnormal bleeding Confusion or problems thinking Pale or clay-colored[medlineplus.gov]
  • Common symptoms associated with hepatitis include: • Dark urine and pale or clay-colored stools • Loss of appetite • Fatigue • Abdominal pain or distention • General itching • Jaundice (yellowing of the skin or eyes) • Nausea and vomiting • Low grade[charcoalremedies.com]
Jaundice
  • Many healthy babies have mild jaundice, especially during the first week or two of life. This normal type of jaundice usually goes away by the time your child is about 2 weeks old.[seattlechildrens.org]
  • Rare disease associated with jaundice, coagulopathy, and hepatic encephalopathy. The aetiology and the interval from onset of jaundice to the development of encephalopathy have a significant impact on prognosis.[bestpractice.bmj.com]
  • Although we lack precise and universally agreed definitions, acute decompensation of chronic liver disease with jaundice and deranged clotting, multi-organ failure and high, short-term mortality are hallmarks of the syndrome.[ncbi.nlm.nih.gov]
  • Although he was wasting and severely jaundiced, his consciousness level was not disturbed at all, with normal serum ammonia blood concentration before LT.[ncbi.nlm.nih.gov]
  • In December 2015, at the time of the patient's progression from his Hodgkin lymphoma after fourth line treatment, he developed persistent fevers, abdominal distension, jaundice and worsening of his liver function tests.[ncbi.nlm.nih.gov]
Asterixis
  • Constructional apraxia Patients cannot reproduce simple designs (e.g. a star of David) Drowsiness and confusion Parotid gland enlargement Spider angiomas Icterus Bilateral parotid swelling ( Credit ) Diminished axillary hair Spider angioma Gynecomastia in a male Asterixis[stanfordmedicine25.stanford.edu]
  • Liver palms are red and an hepatic flap, also called asterixis, may be present. Hyperextend the fingers and wrist, gently pushing back and a slow clonic movement is the liver flap.[patient.info]
  • Clinical features include lethargy and confusion (frequently progressing to coma); asterixis; nystagmus, pathologic; brisk oculovestibular reflexes; decorticate and decerebrate posturing; muscle spasticity; and bilateral extensor plantar reflexes (see[icd10data.com]
  • View/Print Table TABLE 2 Common Physical Examination Findings in Patients with Cirrhosis Abdominal wall vascular collaterals (caput medusa) Ascites Asterixis Clubbing and hypertrophic osteoarthropathy Constitutional symptoms, including anorexia, fatigue[aafp.org]
Scleral Icterus
  • icterus Vascular spiders (spider telangiectasias, spider angiomata) Splenomegaly Testicular atrophy Most patients with cirrhosis severe enough to lead to ascites have additional stigmata of cirrhosis on physical examination.[aafp.org]
  • Jaundice (yellowing of the skin) and scleral icterus (yellowing of the eyes) are often present, but may not be initially noted by patients or their families until relatively late in the course of the illness.[surgery.ucsf.edu]
Liver Palms
  • Liver palms are red and an hepatic flap, also called asterixis, may be present. Hyperextend the fingers and wrist, gently pushing back and a slow clonic movement is the liver flap.[patient.info]
Fetor Hepaticus
  • Fetor hepaticus Constructional apraxia Patients cannot reproduce simple designs (e.g. a star of David) Drowsiness and confusion Parotid gland enlargement Spider angiomas Icterus Bilateral parotid swelling ( Credit ) Diminished axillary hair Spider angioma[stanfordmedicine25.stanford.edu]
  • hepaticus—a sweet, pungent breath odor Gynecomastia Hepatomegaly Jaundice Kayser-Fleischer ring—brown-green ring of copper deposit around the cornea, pathognomonic for Wilson’s disease Nail changes: Muehrcke’s nails—paired horizontal white bands separated[aafp.org]
Delayed Wound Healing
  • Previous studies have found that binge drinking delays wound healing, increases blood loss and makes us more prone to pneumonia and other infections.[dailymail.co.uk]
Dark Urine
  • When the liver is damaged, symptoms often include yellow color in skin and eyes, dark urine, persistent itching, and fatigue. The causes can be viral, as in ... Hepatitis A-E, or can be due to scarring, cirrhosis, or a liver cancer.[sharecare.com]
  • Other symptoms include abdominal pain and swelling, persistent itchy skin, dark urine, pale stools, bloody or black stools, exhaustion, bruising easily, nausea and loss of appetite.[livescience.com]
  • Symptoms may include: Jaundice Dark urine Pale stool Easy bleeding Itching Ascites Chills Pain from the biliary tract or pancreas Enlarged gallbladder Some causes of cholestasis include the following: Hepatitis Alcoholic liver disease Primary biliary[stanfordchildrens.org]
Seizure
  • A case of a 4-month-old infant with hypertransaminasemia, severe coagulopathy, non ketotic hypoglycemia, moderated metabolic acidosis and neurologic symptoms such as seizures and nistagmus is described.[ncbi.nlm.nih.gov]
  • Neuro - Hepatic Encephalopathy, Cerebral Edema, Seizures. Cerebral edema is common in severe encephalopathy and is a major cause of death in acute liver failure (the other common cause of death is sepsis).[errolozdalga.com]
  • Seizures Seizures, which may be seen as a manifestation of the process that leads to hepatic coma and intracranial hypertension (ICH), should be controlled with phenytoin.[emedicine.medscape.com]
  • Call 911 for any of the following: You have a seizure. You lose consciousness or cannot be woken. You have sudden shortness of breath. When should I seek immediate care? You feel lightheaded or are too weak to stand.[drugs.com]
  • Symptoms may include: Impaired consciousness Changes in logical thinking, personality, and behavior Mood changes Impaired judgment Drowsiness Confusion Sluggish speech and movement Disorientation Loss of consciousness Coma Seizures (rare) Muscle stiffness[stanfordchildrens.org]

Workup

As mentioned earlier, liver failure diagnosis is often difficult at the early stage due to symptoms being overly vague and close to other health condition. In some instances, the patient may not present any of the common symptoms even when the liver has already been damaged considerably.

The first step in diagnosis is to obtain medical history from the patient [8]. This will establish the presence of possible risk factors. These factors include prescription drug use, sexual activity, alcohol consumption, exposure to blood products, exposure to toxic chemicals, family history of liver disease, use of injection drugs, etc.

Blood tests are then used to check for liver inflammation and test for antibodies that may indicate liver failure.

Liver biopsy is indicated in some cases and imaging tests like magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP), ultrasound, computerized tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) may be required.

Hyponatremia
  • After admission, although several major symptoms, including diarrhea, ascites, hyponatremia, and hypoproteinemia, were greatly improved through appropriate treatments, his laboratory indicators were not changed much.[ncbi.nlm.nih.gov]
  • Also, severe electrolye abnormalities (hyponatremia, hypophosphatemia, hypokalemia, hypomagnesemia, also metabolic acidosis). Patients often need CVVH. 5.[errolozdalga.com]
  • Large-volume infusions of hypotonic fluids, which may result in hyponatremia and cerebral swelling, should be avoided.[nejm.org]
  • […] levels elevated, usually 300 U/L; AST/ALT ratio 2:1 Hematologic Anemia Leukocytosis or leukopenia Thrombocytopenia Increased serum globulin levels Metabolic Elevated blood ammonia level Hyperglycemia Respiratory alkalosis Hypomagnesemia Hypophosphatemia Hyponatremia[clevelandclinicmeded.com]
Hypocapnia
  • The goals of respiratory care are similar to those in other critical illnesses; hyperventilation to induce hypocapnia may be used for emergent control of intracranial hypertension if the condition is associated with cerebral hyperemia, but sustained hyperventilation[nejm.org]
Decreased Platelet Count
  • Blood examination and imaging revealed a decreased platelet count and splenomegaly. Her liver viability was preserved, and collaterals did not develop, and her tumor thrombosis forced us to perform a right hepatectomy from an oncological standpoint.[ncbi.nlm.nih.gov]

Treatment

Liver failure treatment is dependent on the etiologic factor [9].

Acute liver failure caused by overdose of prescription medications can be treated and the effects can be reversed following early detection. In the same way, liver failure as a result of virus can be treated with supportive care. The supportive care allows the virus to run its course while the liver heals on its own.

Chronic liver failure however, requires actions aimed at salvaging the remains of the liver. Where this is not realistic, a liver transplant will be needed.

Prognosis

The prognosis for this condition is dependent on the etiologic factor in the particular case of liver failure [6].

Both acute and chronic liver failures are unpredictable and there is high mortality and morbidity. Early and accurate diagnosis as well as proper management is vital for increased chances of survival.

For instance patients that have acute liver failure that is caused by acetaminophen have a much better prognosis than those that are dealing with a form of the disorder without a clearly laid out etiology. In patients with stage 3 or 4 encephalopathy, prognosis is also very poor. As soon as a complication like cerebral edema, renal failure or infection arises, the risk of mortality becomes even higher.

Etiology

In chronic liver failure, the main etiologic factors include persistent and excessive alcohol consumption, cirrhosis, hepatitis C, hepatitis B and malnutrition [2]. Excessive absorption and storage of iron (hemochromatosis) can also lead to chronic liver failure [3].

The etiologic factors for acute liver failure on the other hand differ from the factors above. They include ingestion of poisonous wild mushrooms, reactions to some prescriptions (often herbal), hepatitis A, B and C viruses (mostly seen in children) and overdose of acetaminophen.

Epidemiology

In the United States, around 2000 cases of liver failure are reported annually with more than half of these arising from overdose [4]. Around 15% of the cases are a result of unknown etiological factors.

In Europe, the numbers are higher due to the high number of hepatitis B infections but majority of the cases are a result of acetaminophen overdose.

The number of liver failure cases in the developing world is higher than what is obtainable in other locations. A number of environmental factors contribute to this but the high number of hepatitis infections have been fingered as the leading cause of the high incidence.

Sex distribution
Age distribution

Pathophysiology

In patients with liver failure, the development of cerebral edema is the main cause of morbidity and death [5]. The cause of the cerebral edema is still unclear as it is believed that a lot of factors play a role in its development.

It is believed that excessive ammonia in the blood (hyperamonemia) is one of the factors involved in the development of cerebral edema. Over the course of development of the condition, cytokine profiles are often deranged and elevated.

Astrocyte swelling and brain edema arises following the accumulation of glutamine in astrocyte. Increase in intracranial blood volume and cerebral blood flow is another pathophysiological factor in the development.

Prevention

The major way to prevent liver failure is to reduce the risk of developing cirrhosis or hepatitis. This can be achieved with the aid of following [10]:

  • Reduced alcohol intake and total abstinence from it when taking acetaminophen.
  • Regular consumption of a proper diet covering all the classes of food.
  • Regular use of protection when having sexual intercourse.
  • Washing of hands after using public restrooms and before touching any food as well as increased proper hygiene.
  •  Vaccination against hepatitis A or B.
  • Non-sharing of personal toiletry items like razors and toothbrushes.
  • Avoidance of blood and blood products.
  • Avoidance of all body piercing materials especially when it can’t be proven that equipment is aseptic. This should also be adhered to when using any intravenous substances. 

Summary

Liver failure is a condition typified by the inability of the liver to carry out its natural functions. It sets in when large portions of the liver become irreparably damaged [1]. This may be a life threatening ailment and therefore needs emergency medical care.

In most cases, liver failure occurs slowly, with damage spread over a period of years. This is known as chronic liver failure. On the other hand, the condition can start and peak in 48 hours or less. This is referred to as acute liver failure. Acute liver failure is rare and can be difficult to detect.

Patient Information

Liver failure is loss of the functions of the liver. There are two types of liver failure, acute and chronic liver failure. Acute liver failure is a situation where the patient suddenly develops the condition without any former history of liver problems while chronic liver failure is a situation where liver failure develops slower over a few years.

The complications of the disease are often serious and this includes excessive bleeding, increase in pressure in the brain etc. The condition is a medical emergency that requires hospitalization of the patient if proper treatment is to be achieved.

The outcome of treatment depends on the cause of the condition and type of liver failure. However, liver transplant is required in majority of cases.

References

Article

  1. Chalasani NP, Hayashi PH, Bonkovsky HL, et al. ACG clinical guideline: the diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol. Jun 17 2014.
  2. Polson J, Lee WM. AASLD position paper: the management of acute liver failure. Hepatology. May 2005;41(5):1179-97. 
  3. Stravitz RT, Kramer AH, Davern T, Shaikh AO, Caldwell SH, Mehta RL, et al. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med. Nov 2007;35(11):2498-508. 
  4. Bernal W. Intensive care support therapy. Liver Transpl. Sep 2003;9(9):S15-7. 
  5. Akbar N, Tahir RA, Santoso WD, et al. Effectiveness of the analogue of natural Schisandrin C (HpPro) in treatment of liver diseases: an experience in Indonesian patients. Chin Med J (Engl). 1998 Mar;111(3):248-51.
  6. Aleynik SI, Lieber CS. Polyenylphosphatidylcholine corrects the alcohol-induced hepatic oxidative stress by restoring s-adenosylmethionine. Alcohol. 2003 May-Jun;38(3):208–12.
  7. Alwayn IP, Gura K, et al. Omega-3 fatty acid supplementation prevents hepatic steatosis in a murine model of nonalcoholic fatty liver disease. Pediatr Res. 2005 Mar;57(3):445–52.
  8. Boigk G, Stroedter L, et al. Silymarin retards collagen accumulation in early and advanced biliary fibrosis secondary to complete bile duct obliteration in rats. Hepatology. 1997 Sep;26(3):643–9.
  9. Borges-Santos MD, Moreto F, Pereira PC, et al. Plasma glutathione of HIV(+) patients responded positively and differently to dietary supplementation with cysteine or glutamine. Nutrition. Jan 18 2012.
  10. Buzzelli G, Moscarella S, et al. A pilot study on the liver protective effect of silybin-phosphatidylcholine complex (IdB1016) in chronic active hepatitis. Int J Clin Pharmacol Ther Toxicol. 1993 Sep;31(9):456–60.

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Last updated: 2018-06-22 12:18