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Acute Liver Failure

Acute liver failure, also termed fulminant hepatic failure (FHF), is a catastrophic illness that occurs in patients with previously normal liver function. Forms of viral hepatitis cause seventy-five percent of cases of FHF. Hepatitis C is the most common virus to cause FHF. About 1% of patients with hepatitis B may develop FHF. Less commonly, hepatitis A, herpes simplex virus, or delta virus infection superimposed on chronic hepatitis B infection can result in FHF. It is important to note that only a small minority of patients with viral hepatitis will develop FHF.

The remaining 25% of the cases of FHF are non-viral in origin. These may be secondary to adverse drug reactions (e.g. rifampin, isoniazid, inhaled anesthetics), drug overdoses (most notoriously acetaminophen {Tylenol}), toxic inhalations (e.g. carbon tetrachloride), poisonous mushrooms (Amanita phalloides), thrombosis or clotting of the hepatic vein (Budd-Chiari syndrome), shock states (such as severe heart failure), Reye's syndrome, acute alcoholic hepatitis, fatty liver of pregnancy, and Wilson's disease (a disorder of copper metabolism).

There are many severe manifestations of FHF. Early in the illness, the patient's mental status may be mildly abnormal with confusion, irrational behavior, or psychosis. Subsequently, the patient may develop progressive encephalopathy (worsening stupor, delirium, and alteration in sensorium), which may progress to coma. Acute renal failure (in this case termed hepatorenal syndrome) may occur. Severe coagulopathy (overly "thin" non clotting blood), biochemical blood abnormalities (marked elevation of liver function tests, low glucose, sodium, and potassium levels, and lactic acidosis), cardiac arrhythmias, and gastrointestinal bleeding further complicate this disorder.

Treatment of FHF is largely supportive and usually is rendered in the intensive care unit setting. Any exposures that may have caused the FHF (such as toxic ingestions or implicated medications) must be stopped immediately. Basic cardiopulmonary support (which may include placement on an artificial respirator) may be required. The physician must monitor the patient closely for biochemical abnormalities (as mentioned above). Specialized nutritional support is required.

FHF is a life-threatening disorder. Fifty percent or more of patients with this disorder may not survive. Causes of death include severe swelling of the brain, severe infections, gastrointestinal bleeding, renal failure, respiratory failure, or circulatory collapse. Patients that have progressive liver failure in spite supportive measures may be candidates for liver transplantation.

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