Acute liver failure

What is acute liver failure?

Acute liver failure (ALV) is also known as acute hepatic insufficiency. In both cases, this means that the liver stops working completely or partially, even though there was no previous long-term illness. Otherwise (if the liver is already damaged in the long term), one would speak of chronic liver failure.

In addition to acute failure and chronic failure of the liver, there is a third form of liver failure: if the liver has been chronically damaged for a long time and then its condition suddenly deteriorates, doctors call this “acute-on-chronic liver failure”.

The liver is the most important organ for our metabolism. One of its most important tasks is detoxification: it ensures that harmful substances that we ingest with our food are broken down and excreted. The liver is also involved in blood clotting, fat digestion and the production of hormones. And it ensures that vital energy sources (protein, fat, sugar) can be utilized by our body.

The liver is the largest internal organ in our body. If it is damaged or fails, it does not make itself felt through pain. This is because there are no nerve cells in the liver. However, there are clear symptoms that indicate acute liver failure.

Acute liver failure – frequency and age

Acute liver failure (ALV) is the sudden onset of liver insufficiency (inadequate performance) with no evidence of chronic liver disease. It is rare for this important organ to suddenly lose its function without a prolonged previous illness. Around one in every 100,000 people suffers from this disease. In Switzerland, it is roughly estimated that around 50 to 60 people are affected by acute liver failure every year. (In Germany, it is estimated that there are around 500 cases a year, in the USA around 2000).

There are slightly more women than men among those diagnosed with acute liver failure. Older people are affected much more frequently than younger people. But even in newborns and infants, it can happen in rare cases that the liver loses its function without any previous illness.

Acute liver failure: causes and risk factors

If your liver suddenly stops working within a short period of time, there may be various reasons for this. The most important ones:

• Overdose of medication (especially paracetamol)
• Hepatitis (especially hepatitis B, also hepatitis E during pregnancy)
• Ebola viruses
• Yellow fever viruses
• Herpes simplex virus infection
• Cytomegalovirus (CMV infection)
• Mushroom poisoning (e.g. from button mushrooms)
• Drugs (for example ecstasy)
• Chemicals
• The hereditary disease Wilson’s disease
• Complications during pregnancy (e.g. HELLP syndrome)
• Iron storage disease (hemochromatosis) in newborns
• Budd-Chiari syndrome (thrombosis of the hepatic veins)
• Blood poisoning (sepsis)

An overdose of the active ingredient paracetamol is the number one cause of acute liver failure in Europe. In around 20 percent of all cases, the cause of acute liver damage remains unclear. If acute liver failure occurs in children or adolescents, this rate is even higher: in almost 50 percent of cases, it is not possible to determine what caused the damage.

Any physical illness can also be associated with psychological stress. This can manifest itself in worry, tension, circling thoughts or sleep disorders, among other things, and make the course of treatment more difficult. If you or your relatives desire psychiatric-psychological counseling and support, our specialists at the USZ will be happy to assist you.

Symptoms: Acute liver failure

If you experience acute liver failure (ALS), you will not feel any pain in your liver. This organ is insensitive to pain. However, there are clear signs that indicate acute liver failure:

• The white of the eye (called the sclera) turns yellowish.
• Your ability to concentrate decreases.
• You feel tired and exhausted.
• You find it more difficult than usual to speak.
• Her eyelids begin to flutter.
• Bruises form under the skin.
• Later, the skin takes on a yellow hue.

If you suffer from acute liver failure, there is a high risk that you will get a bacterial infection. This is the case for around 80 percent of all ALV recipients. Fungal infections (with the fungus Candida albicans) are just as common.

Acute liver failure: diagnosis with us

If there is a risk of acute liver failure, your doctor will first want to find out whether it really is this sudden form of liver failure. This is because chronic liver disease is much more common. We will therefore look for possible pre-existing conditions. They should indicate or rule out chronic liver failure.

You will therefore certainly be asked whether you are taking medication, whether you drink alcohol and whether you are involved with toxic substances either professionally or privately. It will always be a question of the quantity and duration of the respective intake. We will also consider a possible viral infection that can attack the liver. If the liver failure is already so advanced that your consciousness is clouded, we will try to contact your relatives. You should then provide information about your medical history (anamnesis) on your behalf, as far as this is possible.

Following the medical history, we will examine you.

• A yellow discoloration of your skin or eyes may be visible at first glance. Jaundice is a reliable indication of liver dysfunction.
• The doctor can find out whether your liver has enlarged or shrunk by palpating your abdomen or examining you with an ultrasound machine.
• A blood analysis in the laboratory should determine the so-called liver values. They can provide information about how well your liver is functioning.
• The thromboplastin time is also determined when the blood is examined. This is the time it takes for the blood to clot. If it is prolonged, this indicates acute liver failure.
• We may arrange for a small sample of liver tissue to be taken. This liver biopsy is intended to clarify the condition of your liver. Important note: If you have a serious blood clotting disorder, please make sure to point this out. In this case, a biopsy will probably not be performed. As the liver is heavily supplied with blood, complications can occur during the puncture required to take the sample.

Acute liver failure: prevention, early detection, prognosis

You can prevent acute liver failure. The best thing to do is to spare your liver any serious stress that could trigger acute liver failure. Typical causes of this disease are poisoning, hepatitis and other viral infections.

So make sure you do,

• that you do not overdose on the medication you are taking. This applies in particular to the active ingredient paracetamol.
• that you only eat mushrooms that you are sure are safe.
• that you are cautious when dealing with drugs. (If you are addicted to drugs, make sure you use sterile needles).
• that you are vaccinated against hepatitis before traveling abroad.
• that you use condoms during sexual intercourse if you have the slightest doubt about the health of your sexual partner.

Acute liver insufficiency can also develop following a long-lasting (chronic) liver disease. You should therefore not only avoid the above-mentioned stresses that can lead to acute liver failure, but also prevent chronic liver failure. It is best to refrain from doing anything that could damage your liver.

• Only drink alcoholic beverages in small quantities if possible.
• Eat a healthy diet (especially avoid large amounts of fat and sugar).
• If you suffer from diabetes, have your condition checked regularly. Follow the instructions given to you by your doctor.
• When you travel, make sure that food is prepared hygienically and that drinks are safe to consume, such as water in still-sealed bottles.

Course and prognosis of acute liver failure

Acute liver failure (ALV) is defined as a “sudden” failure of liver function without a prolonged pre-existing liver disease. This does not mean that ALV symptoms appear within minutes or a few hours. The term “sudden” should rather be understood to mean that acute liver failure develops within a few to several days or within a month. The liver is an organ that can still function even with large quantities of damaged cells. It takes a relatively long time for a diseased liver to stop working completely.

If your doctor has diagnosed you with acute liver failure, the course of your illness depends primarily on the underlying cause. Once this cause has been eliminated and the symptoms successfully treated, acute liver failure can also be quickly resolved. Sometimes this can be the case after just a few days, for example after poisoning.

In any case, acute liver failure must be treated quickly. Otherwise the prognosis is poor. As the liver performs a variety of tasks in our body, no human being can live without this organ. The younger an ALV patient is, the better the chances of being cured after acute liver failure. If acute liver failure occurs after chronic liver disease (“acute-on-chronic”), the chances of recovery are lower than in the case of acute liver failure without any previous liver damage.

If an acute functional failure of the liver is not (or not successfully) treated, the course of this disease is usually fatal. In the advanced stage, blood pressure often drops and breathing becomes faster. As the liver can no longer adequately perform its task of detoxifying the blood, toxic substances (e.g. ammonia) enter the brain. The affected person becomes increasingly tired and eventually falls into a coma.

Acute liver failure: effective treatment

Acute liver failure (as well as acute-on-chronic liver failure) should be treated immediately in hospital in an intensive care unit. The correct determination of the underlying cause of the acute liver damage is crucial for the success of the therapy.

If poisoning has caused acute liver failure, your stomach will be washed out and an antidote (also known as an antidote) will be administered. For example, the substance N-acetylcysteine acts as an antidote to an overdose of paracetamol.

An acutely damaged liver can only supply your body with an insufficient amount of important substances such as sugar and blood salts. Infusions of glucose and electrolytes therefore serve as a substitute. We will also try to stabilize your circulation and ensure that blood clotting is maintained. Because your liver only fulfills this task if it is reasonably healthy.

In some cases, despite all therapeutic efforts, it is not possible for the acutely damaged liver to recover, especially if it was already previously damaged. The last therapeutic choice in this case is a liver transplant.