Liver Failure

Liver failure is severe deterioration in liver function.

• Liver failure is caused by a disorder or substance that damages the liver.
• Most people have jaundice (yellow skin and eyes), feel tired and weak, and lose their appetite.
• Other symptoms include accumulation of fluid within the abdomen (ascites) and a tendency to bruise and bleed easily.
• Doctors can usually diagnose liver failure based on symptoms and results of a physical examination and blood tests.
• Treatment usually involves controlling protein consumption, limiting sodium in the diet, completely avoiding alcohol, and treating the cause, but sometimes liver transplantation is required.

Causes

Liver failure can result from many types of liver disorder, including viral hepatitis (most commonly hepatitis B or C), cirrhosis, and liver damage from alcohol or drugs such as acetaminophen.

A large portion of the liver must be damaged before liver failure occurs. Liver failure may develop rapidly over days or weeks (acute) or gradually over months or years (chronic).

Complications

Many effects occur because the liver malfunctions:

• The liver can no longer adequately process bilirubin (a waste product formed when old red blood cells are broken down) so that it can be eliminated from the body. Bilirubin then builds up in the blood and is deposited in the skin. The result is jaundice.
• The liver can no longer synthesize enough of the proteins that help blood clot. The result is a tendency to bruise and bleed (coagulopathy).
• Blood pressure in the veins that bring blood from the intestine to the liver is often abnormally high (called portal hypertension).
• Fluid may accumulate within the abdomen (ascites).
• Brain function may deteriorate because the liver cannot remove toxic substances as it normally does and these substances build up in the blood. This disorder is called hepatic encephalopathy.
• New veins (called collateral vessels) that bypass the liver may form. They often form in the esophagus and the stomach. There, the veins enlarge and become twisted. These veins—called varicose veins of the esophagus (esophageal varices) or stomach (gastric varices)—are fragile and prone to bleeding.
• For unknown reasons, the kidneys malfunction in up to half of people with liver failure. Liver failure that leads to kidney failure is called hepatorenal syndrome.
• The immune system malfunctions, increasing the risk of infections
• People may have metabolic abnormalities, such as a low potassium level in the blood (hypokalemia) or a low blood sugar level (hypoglycemia).

Symptoms

People with liver failure usually have jaundice, ascites, hepatic encephalopathy, and generally failing health. Jaundice makes the skin and whites of the eyes look yellow. Ascites may cause the abdomen to swell. Hepatic encephalopathy may cause confusion or drowsiness. Most people also have general symptoms, such as fatigue, weakness, nausea, and loss of appetite.

The breath may have a musty sweet odor.

People may bruise and bleed easily. For example, bleeding that would be slight in other people (for example, bleeding from a small cut or a nosebleed) may not stop on its own and may even be difficult for doctors to control. Loss of blood can result in low blood pressure (hypotension) and shock.

In acute liver failure, people may go from being healthy to near death within a few days. In chronic liver failure, the deterioration in health may be very gradual until a dramatic event, such as vomiting blood or having bloody stools, occurs. Blood in vomit or stool is usually caused by bleeding from varicose veins in the esophagus and stomach.

If kidney failure develops, less urine is produced and excreted from the body, resulting in the buildup of toxic substances in the blood.

Eventually, breathing becomes difficult.

Ultimately, liver failure is fatal if it is not treated or if the liver disorder is progressive. Even after treatment, liver failure may be irreversible. Some people die of kidney failure. Some people develop liver cancer.

Diagnosis

• A doctor's evaluation
• Blood tests

Doctors can usually diagnose liver failure based on symptoms and the results of a physical examination. Blood tests are done to evaluate liver function, which is usually severely impaired.

To check for possible causes, doctors ask about all substances that people have taken, including prescription and over-the-counter drugs, herbal products, and nutritional supplements. Blood tests are also done to identify possible causes.

Other tests, such as urine tests, other blood tests, and often a chest x-ray, are done to check for problems that can develop, including deterioration of brain function, kidney failure, and infections. Depending on the person's symptoms, tests may be repeated frequently.

Treatment

• Treatment of the cause
• A diet low in animal protein
• For acute liver failure, immediate treatment
• Sometimes liver transplantation

Treatment depends on the cause and the specific symptoms. The urgency of treatment depends on whether liver failure is acute or chronic, but the principles of treatment are the same.

Dietary restriction

People are usually placed on a restricted diet, limiting the amount of animal protein, particularly in red meat but also in fish, cheese, and eggs. Eating too much animal protein can contribute to brain dysfunction. To make sure people get enough protein, doctors advise them to eat more foods that contain vegetable protein (such as soy). People should also limit their consumption of sodium (in salt and many foods). Doing so can help prevent fluid from accumulating within the abdomen. Alcohol is completely avoided because it can worsen liver damage.

Acute liver failure

Acute liver failure is treated as soon as possible because problems (such as bleeding) can develop and worsen quickly. People with acute liver failure are treated in an intensive care unit (ICU) if possible. Treatment may include

• For low blood pressure: Fluids given intravenously and drugs to increase low blood pressure
• For hepatic encephalopathy: Possibly treatments, such as lactulose (a laxative) and antibiotics
• For infections: Antibiotics or antifungal drugs
• For low blood sugar: Glucose (a sugar) given intravenously
• For bleeding: Transfusions of fresh frozen plasma (the fluid part of the blood, which contains proteins that help blood clot, called blood clotting factors) and, when necessary, whole blood

If needed, a plastic breathing tube is inserted through the mouth into the windpipe and sometimes a mechanical ventilator is used to assist with breathing.

Liver transplantation

Liver transplantation, if done soon enough, can restore liver function, sometimes enabling people to live as long as they would have if they did not have a liver disorder. However, liver transplantation is not suitable for all people with liver failure.