How Do You Know If Your Liver Is Failing?

There are many different causes for acute liver failure, including: 

• Drugs
  • Acetaminophen (paracetamol)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Antibiotics
  • Anticonvulsants
  • Azole antifungals
  • Herbal medications and dietary supplements 
  • Chemotherapy drugs
  • Idiosyncratic drug reactions (uncommon reactions to drugs)
• Viruses
  • Hepatitis A, B, C, D, and E
  • Herpes simplex virus
  • Varicella zoster virus
  • Epstein-Barr virus
  • Adenovirus
  • Cytomegalovirus
• Alcoholic hepatitis (in which case it is considered to be acute-on-chronic liver failure) 
• Autoimmune hepatitis
• Toxins
  • Mushroom poisoning (most often Amanita phalloides)
  • Carbon tetrachloride
• Wilson disease
• Ischemic hepatopathy
• Budd-Chiari syndrome
• Veno-occlusive disease
• Acute fatty liver of pregnancy/HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome
• Invasive cancer (most often breast cancer, small cell lung cancer, lymphoma, melanoma, or myeloma)
• Removal of part of the liver (partial hepatectomy)
• Sepsis
• Heat stroke
• Hemophagocytic lymphohistiocytosis (primarily occurs in children) 
• Hypoperfusion of the liver 

Acute liver failure is diagnosed with a patient history and physical examination, along with the following tests: 

• Blood tests:
  • Prothrombin time/INR
  • Blood chemistries (sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose, calcium, magnesium, phosphate, lactate dehydrogenase)
  • Liver blood tests (AST, ALT, alkaline phosphatase, GGT, total and direct bilirubin, albumin)
  • Complete blood count with differential
  • Acetaminophen level
  • Blood toxicology screen 
  • Viral hepatitis serologies 
  • Pregnancy test in women 
  • Autoimmune markers 
  • Blood type and screen
  • HIV testing
  • Amylase and lipase
• Arterial blood gas
• Arterial lactate
• Arterial ammonia
• Urine tests
  • Urine toxicology screen 
  • Urinalysis to look for protein in the urine in women who are pregnant
• Ceruloplasmin level in patients suspected of having Wilson disease
• Anti-hepatitis D virus antibodies in patients with acute or chronic hepatitis B
• Anti-hepatitis E virus antibodies for patients with travel to endemic areas such as Russia, Pakistan, Mexico, India, or Africa
• Imaging studies 
  • Abdominal Doppler ultrasonography 
  • Abdominal computed tomography (CT) scan
  • Venography
  • Magnetic resonance imaging and venography (MRI/MRV)
  • Echocardiogram 
• Liver biopsy 

Treatment for acute liver failure involves treating the underlying cause. Treatments may include: 

• Acetaminophen toxicity 
  • N-acetylcysteine 
• Hepatitis B infection
  • Antiviral therapy with a nucleos(t)ide analogue 
• Mushroom poisoning 
  • Early administration of activated charcoal 
  • Administration of silibinin and penicillin G
• Budd-Chiari syndrome 
  • Transjugular intrahepatic portosystemic shunt placement
  • Surgical decompression
  • Thrombolysis
• Herpes simplex virus infection 
  • Acyclovir 
• Wilson disease 
  • Liver transplantation
  • Plasma exchange to remove copper may act as a temporizing measure
• Autoimmune hepatitis 
  • Glucocorticoids 
  • Liver transplantation for patients who develop encephalopathy
• Acute fatty liver of pregnancy 
  • No specific medical treatment 
  • Treatment is generally prompt delivery (usually emergent) once the mother has been stabilized