Causes of Acute Liver Failure (Fulminant Hepatic Failure)
| Cause | Comment |
|---|---|
| Drug-related | Paracetamol poisoning is the commonest cause of ALF in the UK; AST/ALT are typically >3500 units/L Idiosyncratic reaction (usually occurs within six months of starting drug); many drugs implicated, for example coamoxiclav |
| Viral hepatitis | Hepatitis A, B, C, D or E virus Herpes simplex virus (a rare cause; usually seen in patients taking immunosuppressive therapy or in third trimester of pregnancy) |
| Ischaemic hepatitis (‘shock liver’) | May occur after cardiac arrest or prolonged hypotension, or in severe heart failure, and therefore often associated with acute kidney injury Markedly raised AST/ALT |
| Acute Budd-Chiari syndrome | Due to acute hepatic vein thrombosis Typically occurs in women aged 20–40 years, with underlying haematological disorder (e.g. polycythemia rubra vera, paroxysmal nocturnal haemoglobinuria) or other cause of thrombophilia (P. 567 Table 100.6) Presents with right upper quadrant pain, hepatomegaly and ascites (Chapter 24) Diagnosed by duplex ultrasonography of hepatic veins and IVC |
| Acute fatty liver of pregnancy | Occurs in last trimester of pregnancy Often associated with pre-eclampsia See Chapter 32 |
| Autoimmune hepatitis | Consider if there are other autoimmune disorders (e.g. haemolytic anaemia, idiopathic thrombocytopenic purpura, type 1 diabetes, thyroiditis, coeliac disease) Autoantibodies (antinuclear antibodies, anti-smooth muscle antibodies) and hypergammaglobulinaemia usually present |
| Amanita phalloides poisoning | Suspect if the patient has eaten wild mushrooms Usually associated with severe gastrointestinal poisoning symptoms (nausea, vomiting, diarrhoea, abdominal pain), which develop within hours to one day of ingestion |
| Wilson disease | Suspect in a patient age <30 with liver failure and haemolytic anaemia (giving markedly elevated bilirubin) Kayser-Fleischer rings are present in ∼50% Serum ceruloplasmin is typically low (but may be normal in ∼15% and is often reduced in other forms of ALF) and serum/urinary copper levels high Alkaline phosphatase and urate are low |
| Malignant infiltration | May occur in breast cancer, small cell lung cancer, lymphoma and melanoma Associated with hepatomegaly Diagnosis made by imaging and biopsy |
| Cause unclear | Retake the drug history Consider transjugular liver biopsy |