Last update:
21-Apr-2019

Acute liver failure (ALF) is a syndrome characterized by acute hepatic dysfunction accompanied by encephalopathy and significant of coagulopathy in patients without pre-existing liver damage. The majority of cases worldwide are attributable to viral hepatitis, types A, B (±D) and E. In the developed countries, however, the incidence of drug induced ALF, especially that due to paracetamol overdose, is progressively increasing and in some places it already predominates. Less commonly implicated drugs are anti-tuberculosis medications, antibiotics and antifungals, and herbal supplements. In these cases, the prognosis is poorer than in paracetamol overdose. Autoimmune hepatitis is a rare cause of ALF, for which administration of cortisone early in the course of the disease may be effective. In contrast, Wilson's disease is fatal without liver transplantation when it presents as ALF. The Budd-Chiari syndrome results from obstruction of the venous drainage of the liver. The cornerstone of its treatment is early administration of anticoagulants, but prognosis remains poor. Mushroom poisoning leads to ALF, typically via the effects of the hepatotoxic amanitins of the species Amanita phalloides. Its treatment is mainly supportive, although the use of silybinin, benzylpenicillin and N-acetylcysteine may improve the prognosis. In case of ischemic hepatitis, restoration of the hemodynamic balance leads to rapid improvement of liver function. Malignant infiltration is an unusual cause of ALF, with challenging diagnosis; the most common neoplasms to cause this are breast cancer and lymphoma. Additional causes of ALF which occur specifically in pregnancy are the HELLP syndrome (from Hemolysis, ELevated liver enzymes and Low Platelet count) and acute fatty liver. Termination of the pregnancy is usually enough to stop the liver damage. In order to determine the underlying cause of ALF, a detailed medical and drug history, extensive virological and immunological tests and imaging of the liver parenchyma and its vessels are required. Liver biopsy can rarely be performed with safety, but it can determine the diagnosis only in specific cases.

Key words: Acute liver failure, Acute viral hepatitis, Drug induced liver injury, Liver transplantation.