Chapter 8 - Fulminant and severe acute liver failure

Abstract

This chapter discusses the categories, causes, and pathogenesis of fulminant and severe acute liver failure. Acute liver failure is a rare, clinically heterogeneous, and complex multi-system disorder in which severe impairment of liver function occurs in association with hepatocellular necrosis in a patient with no recognized underlying chronic liver disease. When associated with encephalopathy the term fulminant is applied. In the absence of encephalopathy the severity of the liver impairment is best assessed by the severity of coagulopathy. With toxins such as paracetamol the degree of liver injury is related to the dose of the toxin. In idiosyncratic drug-induced injury, continued drug administration after the onset of jaundice often causes a fatal outcome. Prognosis is influenced by both the age of the patient and competence of the immune system. In severe hepatitis B infection with encephalopathy there is a vigorous immune response with rapid clearance of the virus. The essentials in management are: (1) accurate diagnosis of the cause of the liver injury and of the cause of the encephalopathy; (2) skilled intensive care to minimize aggravating factors and complications until liver function recovers or transplantation can be performed; and (3) liver transplantation in patients in whom the chances of recovery are worse than outcome of emergency liver transplantation.