Ostre niewydolność wątroby

Ostre niewydolność wątroby
Objawy

Ostra niewydolność wątroby (ONW) to nagła utrata funkcji wątroby u osoby bez wcześniejszej choroby wątroby, charakteryzująca się koagulopatią (INR ≥1,5) oraz encefalopatią wątrobową. Początkowo objawy są niespecyficzne (zmęczenie, nudności, bóle brzucha), a do 50% pacjentów może być bezobjawowych. W miarę progresji pojawiają się żółtaczka, encefalopatia (klasyfikowana w 4 stopniach), wodobrzusze, obrzęki i zaburzenia krzepnięcia. Encefalopatia wątrobowa w ONW jest związana z hiperamonemią (poziom amoniaku >100 μmol/l) i obrzękiem mózgu, co zwiększa ryzyko wgłobienia i pogarsza rokowanie. ONW dzieli się na hiperaostrą (encefalopatia w ciągu 7 dni od żółtaczki), ostrą (1-4 tygodnie) i podostrą (4-12 tygodni), a szybka progresja wiąże się z gorszym rokowaniem.

Objawy ostrej niewydolności wątroby

Wczesne objawy niewydolności wątroby
Charakterystyczne objawy rozwijającej się ostrej niewydolności wątroby

Progresja encefalopatii wątrobowej

Stopnie encefalopatii wątrobowej
Mechanizm rozwoju encefalopatii

Klasyfikacja ostrej niewydolności wątroby ze względu na szybkość progresji
Powikłania ostrej niewydolności wątroby

Niewydolność narządowa i zaburzenia metaboliczne
Zaburzenia krzepnięcia i ryzyko krwawienia
Systemowy zespół zapalny i infekcje

Diagnostyka i rozpoznanie
Szczególne cechy progresji w grupach szczególnych

Ostra niewydolność wątroby u kobiet w ciąży
Ostra niewydolność wątroby u dzieci

Rokowanie i przeżywalność
Podsumowanie objawów i progresji ostrej niewydolności wątroby

Kolejne rozdziały

Objawy ostrej niewydolności wątroby

Ostra niewydolność wątroby (ONW) to stan nagłej utraty funkcji wątroby, który występuje zazwyczaj w ciągu dni lub tygodni u osoby bez wcześniejszej choroby wątroby. Stan ten charakteryzuje się gwałtownym pogorszeniem funkcji wątroby z towarzyszącą koagulopatią (INR ≥1,5) oraz encefalopatią wątrobową¹². Ostra niewydolność wątroby może rozwinąć się nagle u zdrowej osoby i stanowi stan zagrażający życiu wymagający natychmiastowej pomocy medycznej³.

Wczesne objawy niewydolności wątroby

Początkowe objawy ostrej niewydolności wątroby są często niespecyficzne i mogą przypominać objawy grypy lub innych powszechnych chorób. Te wczesne symptomy obejmują⁴⁵:

Zmęczenie i osłabienie
Nudności i wymioty
Utratę apetytu
Bóle brzucha, szczególnie w prawym górnym kwadrancie
Biegunkę
Ogólne złe samopoczucie (osłabienie)

Warto zauważyć, że do 50% pacjentów z ostrą chorobą wątroby może nie mieć żadnych objawów⁶. Jest to jeden z powodów, dla których ostra niewydolność wątroby może być trudna do rozpoznania we wczesnym stadium.

Charakterystyczne objawy rozwijającej się ostrej niewydolności wątroby

Wraz z postępem choroby, pojawiają się bardziej charakterystyczne objawy świadczące o zaawansowanej dysfunkcji wątroby⁷⁸:

Żółtaczka – zażółcenie skóry i białkówek oczu, spowodowane nagromadzeniem bilirubiny we krwi
Encefalopatia wątrobowa – zaburzenia funkcji mózgu objawiające się dezorientacją, splątaniem, zmianami osobowości, drżeniami i sennością
Koagulopatia – zaburzenia krzepnięcia prowadzące do łatwego siniaczenia i krwawienia
Wodobrzusze (ascites) – gromadzenie się płynu w jamie brzusznej
Obrzęki – gromadzenie się płynu w kończynach, stopach, dłoniach lub twarzy
Odór z ust o charakterze słodkawym lub stęchłym
Świąd skóry
Ciemne zabarwienie moczu i jasne stolce

Te objawy wskazują na postępującą niewydolność wątroby, gdy toksyny, które normalnie byłyby usuwane przez wątrobę, gromadzą się we krwi⁹.

Progresja encefalopatii wątrobowej

Encefalopatia wątrobowa (EW) jest kluczowym objawem ostrej niewydolności wątroby i stanowi centralny element jej rozpoznania¹⁰. Jest spowodowana nagromadzeniem toksyn we krwi, które nie są prawidłowo oczyszczane przez niewydolną wątrobę, co prowadzi do zaburzeń funkcji mózgu¹¹.

Stopnie encefalopatii wątrobowej

Encefalopatia wątrobowa w przebiegu ostrej niewydolności wątroby rozwija się zazwyczaj postępująco i może być klasyfikowana w następujących stopniach¹²¹³:

Stopień I: Subtelne zmiany zachowania, skrócenie czasu skupienia uwagi, rozdrażnienie, zmiana osobowości, odwrócenie rytmu dobowego snu i czuwania
Stopień II: Dezorientacja, senność, dziwne lub gwałtowne zachowania, problemy z pamięcią
Stopień III: Znaczna splątanie, mowa niewyraźna lub nielogiczna, senność – pacjent śpi większość czasu, ale można go wybudzić na bodźce bólowe
Stopień IV: Śpiączka, brak reakcji na bodźce bólowe

Encefalopatia wątrobowa w przebiegu ostrej niewydolności wątroby różni się od tej występującej w przewlekłej marskości tym, że często wiąże się z obrzękiem mózgu i ryzykiem wgłobienia. Jest to stan znacznie bardziej niebezpieczny¹⁴.

Mechanizm rozwoju encefalopatii

W ostrej niewydolności wątroby encefalopatia rozwija się w wyniku¹⁵¹⁶:

Nagromadzenia amoniaku w krwi (hiperamonemia) – poziom amoniaku powyżej 100 μmol/l przewiduje wystąpienie ciężkiej encefalopatii wątrobowej, a stężenia 150-200 μmol/l korelują z ryzykiem wgłobienia mózgu
Podrażnienia i obrzęku mózgu przez toksyny krążące we krwi
Zmian metabolicznych w mózgu wynikających z zaburzonej funkcji wątroby

Obrzęk mózgu jest głównym czynnikiem wpływającym na rokowanie i jest częstą przyczyną śmiertelności w ostrej niewydolności wątroby¹⁷.

Klasyfikacja ostrej niewydolności wątroby ze względu na szybkość progresji

Ostrą niewydolność wątroby można sklasyfikować w zależności od czasu, jaki upływa od pojawienia się żółtaczki do rozwoju encefalopatii¹⁸¹⁹:

Hiperaostra niewydolność wątroby: encefalopatia rozwija się w ciągu 7 dni od wystąpienia żółtaczki
Ostra niewydolność wątroby: encefalopatia rozwija się w ciągu 1-4 tygodni od wystąpienia żółtaczki
Podostra niewydolność wątroby: encefalopatia rozwija się w ciągu 4-12 tygodni od wystąpienia żółtaczki

Szybkość progresji ma znaczenie dla rokowania. Pacjenci z hiperostą i ostrą niewydolnością wątroby są bardziej narażeni na rozwój obrzęku mózgu i encefalopatii 4 stopnia²⁰.

Powikłania ostrej niewydolności wątroby

Ostra niewydolność wątroby może prowadzić do wielu poważnych powikłań, które dodatkowo pogarszają stan pacjenta²¹²²:

Niewydolność narządowa i zaburzenia metaboliczne

Niewydolność nerek – występuje u ponad 50% pacjentów z ONW, może być spowodowana ostrą martwicą kanalików nerkowych lub zespołem wątrobowo-nerkowym
Hipodynamiczny układ krążenia – rozszerzenie naczyń obwodowych, niskie ciśnienie systemowe, kompensacyjne zwiększenie pojemności minutowej serca
Hiponatremia – prawie uniwersalny objaw spowodowany retencją wody i zaburzeniem transportu sodu wewnątrzkomórkowego
Kwasica mleczanowa – wynikająca z upośledzenia metabolizmu mleczanów przez wątrobę
Hipoglikemia – spowodowana utratą zdolności wątroby do utrzymania prawidłowego poziomu glukozy we krwi

Zaburzenia krzepnięcia i ryzyko krwawienia

Wątroba ma kluczową rolę w syntezie prawie wszystkich czynników krzepnięcia oraz niektórych inhibitorów krzepnięcia i fibrynolizy. Martwica hepatocytów prowadzi do upośledzenia syntezy wielu czynników krzepnięcia i ich inhibitorów²³. Powoduje to:

Zwiększoną skłonność do krwawień i siniaczenia
Krwawienia z nosa, dziąseł
Ryzyko krwawień z przewodu pokarmowego, w tym wymiotów krwią lub treścią przypominającą fusy kawy
Krwawienia wewnętrzne

Systemowy zespół zapalny i infekcje

Około 60% wszystkich pacjentów z ONW spełnia kryteria zespołu ogólnoustrojowej reakcji zapalnej, niezależnie od obecności lub braku infekcji²⁴. Dysfunkcja immunologiczna związana z niewydolnością wątroby zwiększa podatność na infekcje bakteryjne i grzybicze, które mogą dodatkowo pogarszać rokowanie²⁵.

Diagnostyka i rozpoznanie

Rozpoznanie ostrej niewydolności wątroby opiera się na badaniu fizykalnym, wynikach badań laboratoryjnych, wywiadzie od pacjenta oraz wywiadzie dotyczącym przeszłości medycznej w celu ustalenia zmian w stanie psychicznym, koagulopatii, szybkości wystąpienia objawów oraz braku wcześniejszej choroby wątroby²⁶.

Kluczowymi elementami diagnostycznymi są²⁷²⁸:

Ostre podwyższenie enzymów wątrobowych – aktywność aminotransferaz często przekracza 10-krotnie górną granicę normy we wczesnej fazie choroby
Koagulopatia – INR ≥1,5
Encefalopatia wątrobowa – kluczowy objaw dla rozpoznania ONW
Brak wcześniejszej choroby wątroby
Czas trwania choroby krótszy niż 26 tygodni

Szczególne cechy progresji w grupach szczególnych

Ostra niewydolność wątroby u kobiet w ciąży

W późnej ciąży funkcja wątroby znacząco się zmniejsza, co można monitorować za pomocą badań krwi. Wczesne objawy kliniczne ONW w późnej ciąży obejmują²⁹:

Hipodynamia (osłabienie)
Zmniejszenie apetytu
Ciemny bursztynowy mocz
Głęboka żółtaczka
Nudności, wymioty
Wzdęcie brzucha

Ostra niewydolność wątroby u dzieci

Ostra niewydolność wątroby u dzieci jest rzadka. Szansa na wyzdrowienie dziecka zależy głównie od przyczyny i wieku dziecka. Na wyniki leczenia wpływają również stadium choroby i stopień uszkodzenia mózgu³⁰.

U dzieci objawy mogą początkowo przypominać objawy wirusowe, w tym rozstrój żołądka, uczucie stałego zmęczenia lub wymioty. Stan może szybko postępować do żółtaczki, encefalopatii i koagulopatii (problemy z krzepnięciem krwi)³¹.

Rokowanie i przeżywalność

Ostra niewydolność wątroby jest stanem o wysokiej śmiertelności, jednak wprowadzenie intensywnej opieki medycznej i możliwości przeszczepienia wątroby znacząco poprawiło rokowanie³²³³:

Śmiertelność przed erą przeszczepów wynosiła ponad 80%
Obecnie ogólna śmiertelność wynosi około 30-40%
Roczna przeżywalność pacjentów poddanych przeszczepowi wątroby przekracza 65%
Wskaźnik przeżycia bez przeszczepu wzrósł z 33% w 1998 roku do 61% w 2013 roku

Czynnikami wpływającymi na rokowanie są³⁴³⁵:

Etiologia niewydolności wątroby – pacjenci z niewydolnością spowodowaną przedawkowaniem paracetamolu mają lepsze rokowanie niż ci z postacią o niezidentyfikowanej przyczynie
Stopień encefalopatii – pacjenci z encefalopatią 3. lub 4. stopnia mają gorsze rokowanie
Rozwój powikłań, takich jak obrzęk mózgu, niewydolność nerek, zespół ostrej niewydolności oddechowej (ARDS), koagulopatia i infekcje

Wiek pacjenta również ma znaczenie – młodsi pacjenci mają generalnie lepsze rokowanie³⁶.

Podsumowanie objawów i progresji ostrej niewydolności wątroby

Ostra niewydolność wątroby jest stanem charakteryzującym się gwałtowną utratą funkcji wątroby, która może być początkowo trudna do rozpoznania ze względu na niespecyficzne objawy. Kluczowym elementem diagnostycznym jest pojawienie się encefalopatii wątrobowej i koagulopatii³⁷³⁸.

Progresja objawów w ONW może przebiegać następująco³⁹⁴⁰:

Okres prodromalny: zmęczenie, nudności, brak apetytu, dyskomfort w prawym górnym kwadrancie brzucha, złe samopoczucie
Pojawienie się objawów żółtaczki: ciemny mocz, następnie zażółcenie oczu i skóry
Objawy niewydolności wątroby: wodobrzusze, obrzęki obwodowe, koagulopatia
Encefalopatia wątrobowa: od subtelnych zmian zachowania do śpiączki

Czas progresji może być różny – od dni (w przypadku hiperpostrej niewydolności wątroby) do kilku tygodni (w przypadku podostrej niewydolności wątroby)⁴¹.

Ze względu na potencjalnie śmiertelny przebieg, rozpoznanie ostrej niewydolności wątroby wymaga natychmiastowej interwencji medycznej. Pacjenci powinni być leczeni w ośrodkach, w których dostępny jest przeszczep wątroby, gdyż jest to często jedyna opcja ratująca życie⁴²⁴³.

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Materiały źródłowe

#1 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
The main features of acute liver failure are rapid-onset jaundice, weakness, and eventually, changes in mental status that can begin as mild confusion but progress to coma, known as hepatic encephalopathy. […] In ALF, hepatic encephalopathy leads to cerebral edema, coma, brain herniation, and eventually death. Detection of encephalopathy is central to the diagnosis of ALF. It may vary from subtle deficit in higher brain function (e.g. mood, concentration in grade I) to deep coma (grade IV). Patients presenting as acute and hyperacute liver failure are at greater risk of developing cerebral edema and grade IV encephalopathy. […] Coagulopathy is another cardinal feature of ALF. The liver has the central role in the synthesis of almost all coagulation factors and some inhibitors of coagulation and fibrinolysis. Hepatocellular necrosis leads to impaired synthesis of many coagulation factors and their inhibitors.
#2 Acute Liver Failure – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK482374/
Acute liver failure is defined as severe acute liver injury for fewer than twenty-six weeks duration with encephalopathy and impaired synthetic function (INR of 1.5 or higher) in a patient without cirrhosis or preexisting liver disease. […] Acute liver failure (ALF) is a rare and often heterogeneous presentation of severe liver dysfunction in a patient with otherwise no pre-existing liver disease. Though it has high morbidity and mortality, its overall survival has improved through intensive care management and emergency liver transplantation advancements. […] A high index of suspicion, early referral to a specialist liver transplantation center, and adequate supportive management remain the cornerstone for the management of ALF. […] ALF is defined as the development of severe acute liver injury with encephalopathy and impaired synthetic function (INR of 1.5 or higher) in a patient without cirrhosis or preexisting liver disease and with an illness of fewer than 26 weeks duration.
#3 Acute liver failure – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/acute-liver-failure/symptoms-causes/syc-20352863
Acute liver failure is loss of liver function that happens quickly in days or weeks usually in a person who has no preexisting liver disease. Acute liver failure, also known as fulminant hepatic failure, can cause serious complications, including bleeding and increased pressure in the brain. Symptoms of acute liver failure may include: Yellowing of the skin and eyeballs, called jaundice. Pain in the upper right belly area, called the abdomen. A swollen belly, known as ascites. Nausea and vomiting. A general sense of feeling unwell, known as malaise. Disorientation or confusion. Sleepiness. Breath with a musty or sweet odor. Tremors. Acute liver failure can develop quickly in an otherwise healthy person, and it is life-threatening. If you or someone you know suddenly develops a yellowing of the eyes or skin; tenderness in the upper belly; or any unusual changes in mental state, personality or behavior, seek medical attention right away. Some cases of acute liver failure have no obvious cause.
#4 Signs & Symptoms of Liver Failure, Causes, Treatments
https://my.clevelandclinic.org/health/diseases/17819-liver-failure
Acute liver failure happens suddenly, when something overwhelms your liver’s capacity to cope. Its usually a large toxic load, like poisoning. Sometimes, its a severe viral infection. In acute liver failure, your liver rapidly begins to shut down, causing immediate symptoms. This is a medical emergency. […] Symptoms of liver failure include jaundice, dark urine and itching with no rash. Symptoms of liver failure include general feelings of illness along with signs of bile building up in your body. […] You may notice different signs and symptoms of liver failure based on how advanced it is and which complications have begun to occur. The first symptoms of chronic or acute liver failure may include: Abdominal pain (especially in the upper right). Fatigue and malaise (feeling unwell). Nausea, vomiting and loss of appetite.
#5 Liver Failure: Causes, Symptoms, Treatments, Tests & More
https://www.webmd.com/fatty-liver-disease/digestive-diseases-liver-failure
The early symptoms of liver failure are often similar to those of other conditions. Because of this, liver failure may be tough to diagnose at first. Early symptoms include: Nausea, Loss of appetite, Fatigue, Diarrhea. […] As liver failure progresses, the symptoms become more serious, needing care right away. These symptoms include: Jaundice (yellowing of eyes and skin), Bleeding easily, Swollen belly, Mental confusion (known as hepatic encephalopathy), Sleepiness. […] These symptoms will appear in both chronic and acute liver failure. […] The causes of acute liver failure, when the liver fails rapidly, include: Acetaminophen overdose: Large doses can damage your liver or lead to failure. […] Liver failure can be acute (sudden) or chronic (ongoing). Signs of liver failure include yellowing of the skin and eyes (jaundice), swelling of the ankles and stomach, itchy skin, constant tiredness, and loss of appetite. You can have chronic liver failure for years with no symptoms.
#6 Symptoms of Liver Disease – Viral Hepatitis and Liver Disease
https://www.hepatitis.va.gov/basics/liver-disease-symptoms.asp
If something happens to the liver suddenly, it is acute. Some acute liver problems will cause symptoms suddenly as well. Symptoms of acute liver disease can include: […] Up to half of all people with acute liver disease have no symptoms at all. Some types of acute liver disease get better without treatment, and the liver heals itself entirely. On rare occasions an acute liver injury can require hospitalization and even liver transplant right away.
#7 Signs & Symptoms of Liver Failure, Causes, Treatments
https://my.clevelandclinic.org/health/diseases/17819-liver-failure
The first warning signs of a damaged liver that’s starting to fail are signs of bile and other toxins building up in your blood. These may include: Jaundice (yellow tint to the whites of your eyes and skin). Hepatic encephalopathy (altered mental status). Pruritus (itchy skin, but with no visible rash). Dark-colored pee (urine) and/or light-colored poop (stool). […] Other serious signs of liver failure include: Ascites (abdominal swelling with fluid). Edema (swelling with fluid in your ankles, feet, hands or face). Vomiting blood or vomit that looks like coffee grounds. Motor dysfunction (twitching, tremors or lapses in muscle control). Low urine output. Shortness of breath. […] Liver failure will cause toxins to flood your bloodstream, which feels pretty terrible. When your liver can’t filter toxins from your blood anymore, you’ll feel nauseous, tired and weak. Toxins may also infiltrate your brain, causing confusion, irritability, anxiety, drowsiness or motor dysfunction.
#8 Acute Liver Failure – LiverTox – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK548171/
Last Update: December 11, 2019. […] Drug induced acute liver failure is defined by the appearance of signs or symptoms of hepatic failure and encephalopathy during the course of acute drug induced liver injury in a patient without previous or underlying chronic liver disease. […] Symptoms are those of severe acute liver injury, usually with a prodromal period of fatigue, nausea, poor appetite and right upper quadrant discomfort followed by dark urine and jaundice followed by signs or symptoms of hepatic failure. The diagnosis of acute liver failure is actually based upon the appearance of clinical symptoms of hepatic encephalopathy, such as mental clouding, confusion, asterixis, somnolence, stupor and coma. Other features of liver failure include abdominal swelling due to ascites, peripheral edema and coagulopathy. The rapidity of onset of the symptoms of hepatic encephalopathy varies greatly. Cases in which symptoms of encephalopathy arise within days of onset of hepatitis are usually referred to as „hyperacute”, within 5 days to 8 weeks of onset as „acute”, and after 8 weeks of onset as „subacute”. Initial symptoms of hepatic encephalopathy may be subtle and include a change in personality, forgetfulness, reversal of day-night pattern of wakefulness, and irrational or violent behavior.
#9
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=ack1857
Acute liver failure is sudden damage to the liver that keeps it from working as it should and may be life-threatening. The illness may develop in days to weeks. How long it takes depends on its cause. […] A damaged liver allows toxins to build up in your blood. The toxins may cause confusion, slurred speech, and tremors. This is called hepatic encephalopathy. Your liver may also stop making blood clotting factors and certain proteins in your blood. This can lead to serious bleeding and a buildup of fluids in the belly (ascites) and legs. […] Symptoms of acute liver failure may include: Yellow colour of the skin and the white part of the eyes. (This is called jaundice). Nausea and vomiting. Pain in the upper right belly. Feeling tired. Loss of appetite. Itching. Fever. Dark-coloured stools. Fluid buildup in the belly, legs, and arms. Easy bruising. Changes in behaviour, confusion, slurred speech, and hand tremors. Symptoms can suddenly become severe and life-threatening.
#10 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
The main features of acute liver failure are rapid-onset jaundice, weakness, and eventually, changes in mental status that can begin as mild confusion but progress to coma, known as hepatic encephalopathy. […] In ALF, hepatic encephalopathy leads to cerebral edema, coma, brain herniation, and eventually death. Detection of encephalopathy is central to the diagnosis of ALF. It may vary from subtle deficit in higher brain function (e.g. mood, concentration in grade I) to deep coma (grade IV). Patients presenting as acute and hyperacute liver failure are at greater risk of developing cerebral edema and grade IV encephalopathy. […] Coagulopathy is another cardinal feature of ALF. The liver has the central role in the synthesis of almost all coagulation factors and some inhibitors of coagulation and fibrinolysis. Hepatocellular necrosis leads to impaired synthesis of many coagulation factors and their inhibitors.
#11 Acute Liver Failure (ALF) – EMCrit Project
https://emcrit.org/ibcc/alf/
Hyperacute liver failure (HALF): 1 week from jaundice to encephalopathy. […] Acute liver failure: 1-4 weeks from jaundice to encephalopathy. […] Subacute liver failure (SALF): 4-12 weeks from jaundice to encephalopathy. […] Jaundice, although this may not be prominent. […] Encephalopathy, graded as follows: Grade I: Patient shows altered behavior with normal level of consciousness, reduced attention span. […] Grade II: Patient displays altered behavior with disorientation, drowsiness. […] Grade III: Patient is confused, incoherent, mostly sleeping but arousable to painful stimuli. […] Grade IV: Patient is comatose and unresponsive to pain. […] Other findings may include: Nausea/vomiting, anorexia. […] Right upper quadrant pain. […] Pruritus. […] Distension due to ascites.
#12 Loss of brain function – liver disease: MedlinePlus Medical EncyclopediaLock
https://medlineplus.gov/ency/article/000302.htm
Symptoms of HE are graded on a scale of grades 1 to 4. They may begin slowly and worsen over time. […] Early symptoms may be mild and include: Breath with a musty or sweet odor, Changes in sleep patterns, Changes in thinking, Mild confusion, Forgetfulness, Personality or mood changes, Poor concentration and judgment, Worsening of handwriting or loss of other small hand movements. […] Severe symptoms may include: Abnormal movements or shaking of hands or arms, Agitation, excitement, or seizures (occur rarely), Disorientation, Drowsiness or confusion, Behavior or personality changes, Slurred speech, Slowed or sluggish movement. […] People with HE can become unconscious, unresponsive, and possibly enter into a coma. […] The outlook of HE depends on the management of the cause of HE. Chronic forms of the disorder often continue to get worse and come back. The first two stages of the disease have a good prognosis. Stage three and four have a poor prognosis.
#13 Acute Liver Failure (ALF) – EMCrit Project
https://emcrit.org/ibcc/alf/
Hyperacute liver failure (HALF): 1 week from jaundice to encephalopathy. […] Acute liver failure: 1-4 weeks from jaundice to encephalopathy. […] Subacute liver failure (SALF): 4-12 weeks from jaundice to encephalopathy. […] Jaundice, although this may not be prominent. […] Encephalopathy, graded as follows: Grade I: Patient shows altered behavior with normal level of consciousness, reduced attention span. […] Grade II: Patient displays altered behavior with disorientation, drowsiness. […] Grade III: Patient is confused, incoherent, mostly sleeping but arousable to painful stimuli. […] Grade IV: Patient is comatose and unresponsive to pain. […] Other findings may include: Nausea/vomiting, anorexia. […] Right upper quadrant pain. […] Pruritus. […] Distension due to ascites.
#14 Acute Liver Failure (ALF) – EMCrit Project
https://emcrit.org/ibcc/alf/
Labs suggesting active or impending hepatic failure may include: INR 1.5. […] Marked hyperbilirubinemia. […] Severe elevation of transaminases. […] Frank metabolic failure of the liver may eventually cause: Lactic acidosis. […] Hypoglycemia. […] Hyperammonemia. […] The greatest life threat is often acute hepatic encephalopathy, which is frequently associated with increased intracranial pressure and herniation. […] This is far more dangerous than hepatic encephalopathy seen in chronic cirrhosis (which isn’t associated with cerebral edema or herniation). […] Ammonia levels may be the strongest risk factor, as this seems to be a primary driver of cerebral edema: 100 uM/L predicts the onset of severe hepatic encephalopathy. […] 150-200 uM/L correlates with risk of herniation. […] The main sign of ICP elevation is severe encephalopathy.
#15 Acute Liver Failure | Children’s Liver Disease Foundation
https://childliverdisease.org/liver-information/childhood-liver-conditions/acute-liver-failure/
Encephalopathy can occur because the liver is unable to clear toxins from the blood properly. This can lead to irritation and swelling of the brain. If there is a decrease in your childs level of consciousness, leading to drowsiness, irritability or behaviour which is out of character, they may need to be cared for in an intensive care until. […] When the liver fails the kidneys may not work as well as they should. In this case children are given fluids via a drip and a medicine to help them pass urine. They may also need a urinary catheter to accurately measure their urine output. Some children may need help from kidney dialysis for a short time. […] Some children make a complete recovery without the need for liver transplantation. The liver has the ability to recover quickly despite significant injury and sometimes a full recovery is possible.
#16 Acute Liver Failure (ALF) – EMCrit Project
https://emcrit.org/ibcc/alf/
Labs suggesting active or impending hepatic failure may include: INR 1.5. […] Marked hyperbilirubinemia. […] Severe elevation of transaminases. […] Frank metabolic failure of the liver may eventually cause: Lactic acidosis. […] Hypoglycemia. […] Hyperammonemia. […] The greatest life threat is often acute hepatic encephalopathy, which is frequently associated with increased intracranial pressure and herniation. […] This is far more dangerous than hepatic encephalopathy seen in chronic cirrhosis (which isn’t associated with cerebral edema or herniation). […] Ammonia levels may be the strongest risk factor, as this seems to be a primary driver of cerebral edema: 100 uM/L predicts the onset of severe hepatic encephalopathy. […] 150-200 uM/L correlates with risk of herniation. […] The main sign of ICP elevation is severe encephalopathy.
#17 Acute Liver Failure | Annals of Hepatology
https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-acute-liver-failure-S1665268119316734
Acute liver failure is a rare but often catastrophic illness affecting the liver and multiple organ systems. Patients with acute liver failure require a multidisciplinary approach for adequate management. […] The onset and duration of illness must be less than 26 weeks duration. ALF is a challenging medical emergency requiring immediate attention. Progression is associated with multiple organ failure and need for urgent liver transplant, a life-saving option for many ALF patients. […] The presenting symptoms of ALF are frequently non-specific and include fatigue, malaise, anorexia, abdominal pain, fever and jaundice. These symptoms progress in no particular order to coagulopathy preceding the development of encephalopathy, both of which are the hallmark of ALF. […] Advanced ALF often involves dysfunction of multiple organ systems. […] Cerebral edema has a major prognostic role and is a common cause of mortality in ALF. Prompt recognition and treatment is vital. […] The severity of encephalopathy (grade 3 and 4), associated with cerebral edema and coagulopathy have inverse correlation with survival.
#18 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice
https://bestpractice.bmj.com/topics/en-gb/1010
Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy. […] Occurs in patients with no pre-existing liver disease and may result in severe liver impairment and rapid clinical deterioration. […] The aetiology and the interval from onset of jaundice to the development of encephalopathy have a significant impact on prognosis. […] ALF may be classified as hyperacute, acute, or subacute, depending on the interval from the onset of jaundice to the development of encephalopathy.
#19 Acute Liver Failure (ALF) – EMCrit Project
https://emcrit.org/ibcc/alf/
Hyperacute liver failure (HALF): 1 week from jaundice to encephalopathy. […] Acute liver failure: 1-4 weeks from jaundice to encephalopathy. […] Subacute liver failure (SALF): 4-12 weeks from jaundice to encephalopathy. […] Jaundice, although this may not be prominent. […] Encephalopathy, graded as follows: Grade I: Patient shows altered behavior with normal level of consciousness, reduced attention span. […] Grade II: Patient displays altered behavior with disorientation, drowsiness. […] Grade III: Patient is confused, incoherent, mostly sleeping but arousable to painful stimuli. […] Grade IV: Patient is comatose and unresponsive to pain. […] Other findings may include: Nausea/vomiting, anorexia. […] Right upper quadrant pain. […] Pruritus. […] Distension due to ascites.
#20 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
The main features of acute liver failure are rapid-onset jaundice, weakness, and eventually, changes in mental status that can begin as mild confusion but progress to coma, known as hepatic encephalopathy. […] In ALF, hepatic encephalopathy leads to cerebral edema, coma, brain herniation, and eventually death. Detection of encephalopathy is central to the diagnosis of ALF. It may vary from subtle deficit in higher brain function (e.g. mood, concentration in grade I) to deep coma (grade IV). Patients presenting as acute and hyperacute liver failure are at greater risk of developing cerebral edema and grade IV encephalopathy. […] Coagulopathy is another cardinal feature of ALF. The liver has the central role in the synthesis of almost all coagulation factors and some inhibitors of coagulation and fibrinolysis. Hepatocellular necrosis leads to impaired synthesis of many coagulation factors and their inhibitors.
#21 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
Kidney failure is common, present in more than 50% of ALF patients, either due to original insult such as paracetamol resulting in acute tubular necrosis or from hyperdynamic circulation leading to hepatorenal syndrome or functional kidney failure. […] About 60% of all ALF patients fulfil the criteria for systemic inflammatory syndrome irrespective of presence or absence of infection. […] Hyponatraemia is an almost universal finding due to water retention and a shift in intracellular sodium transport from inhibition of Na/K ATPase. […] Hyperdynamic circulation, with peripheral vasodilatation from low systemic vascular resistance, leads to hypotension. There is a compensatory increase in cardiac output. […] In late pregnancy liver function decreases significantly, which can be easily monitored by blood tests. Early clinical manifestations of ALF in late pregnancy include hypodynamia, decrease in appetite, dark amber urine, deep jaundice, nausea, vomiting, and abdominal distention.
#22 Acute Liver Failure: Practice Essentials, Background, Pathophysiology
https://emedicine.medscape.com/article/177354-overview
Acute liver failure is an uncommon condition in which rapid deterioration of liver function results in coagulopathy, usually with an international normalized ratio (INR) of greater than 1.5, and alteration in the mental status (encephalopathy) of a previously healthy individual. Acute liver failure often affects young people and carries a very high mortality. […] Signs and symptoms of acute failure may include the following: Encephalopathy, Cerebral edema: May lead to signs of increased intracranial pressure (ICP) (eg, papilledema, hypertension, bradycardia), Jaundice: Often present but not always, Ascites: Potential for hepatic vein thrombosis with rapid development in the presence of fulminant hepatic failure accompanied by abdominal pain, Right upper quadrant tenderness: Variably present, Change in liver span: May be small due to hepatic necrosis or may be enlarged due to heart failure, viral hepatitis, or Budd-Chiari syndrome, Hematemesis or melena: Due to upper gastrointestinal (GI) bleeding, Hypotension and tachycardia: Due to reduced systemic vascular resistance.
#23 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
The main features of acute liver failure are rapid-onset jaundice, weakness, and eventually, changes in mental status that can begin as mild confusion but progress to coma, known as hepatic encephalopathy. […] In ALF, hepatic encephalopathy leads to cerebral edema, coma, brain herniation, and eventually death. Detection of encephalopathy is central to the diagnosis of ALF. It may vary from subtle deficit in higher brain function (e.g. mood, concentration in grade I) to deep coma (grade IV). Patients presenting as acute and hyperacute liver failure are at greater risk of developing cerebral edema and grade IV encephalopathy. […] Coagulopathy is another cardinal feature of ALF. The liver has the central role in the synthesis of almost all coagulation factors and some inhibitors of coagulation and fibrinolysis. Hepatocellular necrosis leads to impaired synthesis of many coagulation factors and their inhibitors.
#24 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
Kidney failure is common, present in more than 50% of ALF patients, either due to original insult such as paracetamol resulting in acute tubular necrosis or from hyperdynamic circulation leading to hepatorenal syndrome or functional kidney failure. […] About 60% of all ALF patients fulfil the criteria for systemic inflammatory syndrome irrespective of presence or absence of infection. […] Hyponatraemia is an almost universal finding due to water retention and a shift in intracellular sodium transport from inhibition of Na/K ATPase. […] Hyperdynamic circulation, with peripheral vasodilatation from low systemic vascular resistance, leads to hypotension. There is a compensatory increase in cardiac output. […] In late pregnancy liver function decreases significantly, which can be easily monitored by blood tests. Early clinical manifestations of ALF in late pregnancy include hypodynamia, decrease in appetite, dark amber urine, deep jaundice, nausea, vomiting, and abdominal distention.
#25 Acute Liver Failure: Symptoms & Treatment | Cardinal Glennon
https://www.ssmhealth.com/cardinal-glennon/services/pediatric-transplant/pediatric-liver-transplant/acute-liver-failure
Acute liver failure (ALF; or fulminant hepatic failure) is a loss of liver function that occurs very rapidly, usually in days or weeks, in a person with no pre-existing liver disease. […] The signs of acute liver failure usually present themselves very quickly and unexpectedly. The first symptom for many adults is an altered mental state (encephalopathy), such as sudden personality shifts or confusion. Infants and children may not experience encephalopathy or exhibit noticeable signs, but will usually have jaundice symptoms (yellowing of the skin and whites of the eyes). […] Other common symptoms: Bleeding (coagulopathy; problems with blood clotting), Extreme fatigue, Nausea or poor appetite, Abdominal discomfort, Vomiting, Fever, Enlarged liver and/or painful abdomen. […] Kidney failure is common in those with ALF, occurring more than 50% of the time. Other organs may also be affected, and bacterial and fungal infections are common. […] If you suspect that you or loved one has symptoms of acute liver failure, go to your nearest emergency room immediately.
#26 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
The diagnosis of acute liver failure is based on physical exam, laboratory findings, patient history, and past medical history to establish mental status changes, coagulopathy, rapidity of onset, and absence of known prior liver disease respectively. […] The advent of transplantation has changed survival from as low as 15% in the pretransplant era to more than 60% today. Liver transplantation is indicated for many patients with ALF, and survival rates of 5690% can be achieved.
#27 Acute Liver Failure – LiverTox – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK548171/
The diagnosis of acute liver failure requires the finding of liver test abnormalities indicative of acute liver injury, accompanied by signs or symptoms of hepatic encephalopathy in a patient with no known previous liver injury. Typical features of acute liver failure include: Acute elevations in serum enzyme elevations with serum aminotransferase levels greater than 10 times the upper limit of the normal range, early in the course of illness. […] Acute liver failure arises typically in patients with acute hepatocellular injury with an acute viral hepatitis like phenotype. Acute hepatic necrosis can also lead to acute liver failure, generally with a hyperacute presentation. Finally, sinusoidal obstruction syndrome and acute fatty liver with lactic acidosis may cause acute liver failure, but clinical features are usually quite different and different medications are typically implicated.
#28 Acute liver failure – Knowledge @ AMBOSS
https://www.amboss.com/us/knowledge/acute-liver-failure/
In hyperacute liver failure, jaundice is usually minimal and the predominant presentation is encephalopathy, which can delay diagnosis and management. […] ALF can cause multiorgan dysfunction, which requires system-based management in a critical care unit. […] ALF diagnosis requires the presence of abnormal liver chemistries, coagulopathy (INR 1.5), and encephalopathy. […] Advances in management have improved outcomes for ALF patients, but prognosis remains poor (overall mortality of 30-40%) and is worse for ALF of indeterminate etiology. Survival without liver transplant depends on etiology.
#29 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
Kidney failure is common, present in more than 50% of ALF patients, either due to original insult such as paracetamol resulting in acute tubular necrosis or from hyperdynamic circulation leading to hepatorenal syndrome or functional kidney failure. […] About 60% of all ALF patients fulfil the criteria for systemic inflammatory syndrome irrespective of presence or absence of infection. […] Hyponatraemia is an almost universal finding due to water retention and a shift in intracellular sodium transport from inhibition of Na/K ATPase. […] Hyperdynamic circulation, with peripheral vasodilatation from low systemic vascular resistance, leads to hypotension. There is a compensatory increase in cardiac output. […] In late pregnancy liver function decreases significantly, which can be easily monitored by blood tests. Early clinical manifestations of ALF in late pregnancy include hypodynamia, decrease in appetite, dark amber urine, deep jaundice, nausea, vomiting, and abdominal distention.
#30 Acute Liver Failure | Symptoms, Diagnosis & Treatment
https://www.cincinnatichildrens.org/health/a/acute-liver-failure
Acute liver failure (ALF) occurs when many cells in the liver die or become very damaged in a short amount of time. This causes the liver to fail to work as it should. […] Symptoms of acute liver failure can be like those of a virus. This can include upset stomach, feeling tired all the time, or throwing up. This can quickly progress to jaundice (yellowing of the skin), encephalopathy and coagulopathy (problem with blood clotting). […] In encephalopathy the brain does not work the way it should. This happens when the liver is not able to break down or get rid of toxic products. A liver that is working like it should is able to break down toxins and carry them out of the liver. […] Acute liver failure in children is rare. The chance the child will recover depends mainly on the cause and their age. The stage of the disease and the amount of brain damage also affect recovery. If the liver heals itself, most often there is a full recovery.
#31 Pediatric Acute Liver Failure | Children’s Hospital Colorado
https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/acute-liver-failure/
Acute liver failure (ALF) happens when the liver is no longer able to perform critical functions such as creating proteins, removing toxins from the blood and keeping blood sugar levels even. […] Acute liver failure occurs when many cells in the liver die in a short period of time or the liver becomes damaged. Pediatric liver failure is not as common as liver failure in adults and liver failure in children is typically very rare. […] Acute liver failure can occur in children of all ages, from newborns to adolescents, and the causes vary widely. […] Children with acute liver failure may have flu-like symptoms, including fatigue, nausea, vomiting and fever. They may also show signs and symptoms resulting from liver failure, such as: Abdominal pain, Jaundice (yellow skin or eyes), Enlarged liver or spleen, Easily bleeding or bruising, Irritability or an altered mental state.
#32 Acute Liver Failure: Practice Essentials, Background, Pathophysiology
https://emedicine.medscape.com/article/177354-overview
The most important step in the assessment of patients with acute liver failure is to identify the cause, because certain conditions necessitate immediate and specific treatment and affect prognosis. […] The outcome of acute liver failure is related to the etiology, the degree of encephalopathy, and related complications. Although mortality from FHF remains significantly high, improved intensive care measures and the use of orthotopic liver transplantation have improved survival from less than 20% to approximately 60%. […] Patients with acute liver failure caused by acetaminophen have a better prognosis than those with an indeterminate form of the disorder. Patients with stage 3 or 4 encephalopathy have a poor prognosis. The risk of mortality increases with the development of any complications, which include cerebral edema, renal failure, adult respiratory distress syndrome (ARDS), coagulopathy, and infection.
#33 Acute Liver Failure – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK482374/
The expected clinical outcomes have drastically changed since ALF was first defined approximately 50 years ago. The current 1-year survival rate of patients, including those undergoing liver transplantation, is greater than 65%. […] The most widely used criteria for determining ALF prognosis are the King’s College Criteria for ALF due to acetaminophen overdose and ALF not associated with acetaminophen.
#34 Acute Liver Failure | Annals of Hepatology
https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-acute-liver-failure-S1665268119316734
Acute liver failure is a rare but often catastrophic illness affecting the liver and multiple organ systems. Patients with acute liver failure require a multidisciplinary approach for adequate management. […] The onset and duration of illness must be less than 26 weeks duration. ALF is a challenging medical emergency requiring immediate attention. Progression is associated with multiple organ failure and need for urgent liver transplant, a life-saving option for many ALF patients. […] The presenting symptoms of ALF are frequently non-specific and include fatigue, malaise, anorexia, abdominal pain, fever and jaundice. These symptoms progress in no particular order to coagulopathy preceding the development of encephalopathy, both of which are the hallmark of ALF. […] Advanced ALF often involves dysfunction of multiple organ systems. […] Cerebral edema has a major prognostic role and is a common cause of mortality in ALF. Prompt recognition and treatment is vital. […] The severity of encephalopathy (grade 3 and 4), associated with cerebral edema and coagulopathy have inverse correlation with survival.
#35 Acute Liver Failure: Practice Essentials, Background, Pathophysiology
https://emedicine.medscape.com/article/177354-overview
The most important step in the assessment of patients with acute liver failure is to identify the cause, because certain conditions necessitate immediate and specific treatment and affect prognosis. […] The outcome of acute liver failure is related to the etiology, the degree of encephalopathy, and related complications. Although mortality from FHF remains significantly high, improved intensive care measures and the use of orthotopic liver transplantation have improved survival from less than 20% to approximately 60%. […] Patients with acute liver failure caused by acetaminophen have a better prognosis than those with an indeterminate form of the disorder. Patients with stage 3 or 4 encephalopathy have a poor prognosis. The risk of mortality increases with the development of any complications, which include cerebral edema, renal failure, adult respiratory distress syndrome (ARDS), coagulopathy, and infection.
#36 Acute liver failure – USZ
https://www.usz.ch/en/disease/acute-liver-failure/
In any case, acute liver failure must be treated quickly. Otherwise the prognosis is poor. As the liver performs a variety of tasks in our body, no human being can live without this organ. The younger an ALV patient is, the better the chances of being cured after acute liver failure. If acute liver failure occurs after chronic liver disease (acute-on-chronic), the chances of recovery are lower than in the case of acute liver failure without any previous liver damage. […] If an acute functional failure of the liver is not (or not successfully) treated, the course of this disease is usually fatal. In the advanced stage, blood pressure often drops and breathing becomes faster. As the liver can no longer adequately perform its task of detoxifying the blood, toxic substances (e.g. ammonia) enter the brain. The affected person becomes increasingly tired and eventually falls into a coma.
#37 Acute liver failure – Wikipedia
https://en.wikipedia.org/wiki/Acute_liver_failure
The main features of acute liver failure are rapid-onset jaundice, weakness, and eventually, changes in mental status that can begin as mild confusion but progress to coma, known as hepatic encephalopathy. […] In ALF, hepatic encephalopathy leads to cerebral edema, coma, brain herniation, and eventually death. Detection of encephalopathy is central to the diagnosis of ALF. It may vary from subtle deficit in higher brain function (e.g. mood, concentration in grade I) to deep coma (grade IV). Patients presenting as acute and hyperacute liver failure are at greater risk of developing cerebral edema and grade IV encephalopathy. […] Coagulopathy is another cardinal feature of ALF. The liver has the central role in the synthesis of almost all coagulation factors and some inhibitors of coagulation and fibrinolysis. Hepatocellular necrosis leads to impaired synthesis of many coagulation factors and their inhibitors.
#38 Acute Liver Failure – LiverTox – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK548171/
Last Update: December 11, 2019. […] Drug induced acute liver failure is defined by the appearance of signs or symptoms of hepatic failure and encephalopathy during the course of acute drug induced liver injury in a patient without previous or underlying chronic liver disease. […] Symptoms are those of severe acute liver injury, usually with a prodromal period of fatigue, nausea, poor appetite and right upper quadrant discomfort followed by dark urine and jaundice followed by signs or symptoms of hepatic failure. The diagnosis of acute liver failure is actually based upon the appearance of clinical symptoms of hepatic encephalopathy, such as mental clouding, confusion, asterixis, somnolence, stupor and coma. Other features of liver failure include abdominal swelling due to ascites, peripheral edema and coagulopathy. The rapidity of onset of the symptoms of hepatic encephalopathy varies greatly. Cases in which symptoms of encephalopathy arise within days of onset of hepatitis are usually referred to as „hyperacute”, within 5 days to 8 weeks of onset as „acute”, and after 8 weeks of onset as „subacute”. Initial symptoms of hepatic encephalopathy may be subtle and include a change in personality, forgetfulness, reversal of day-night pattern of wakefulness, and irrational or violent behavior.
#39 Liver Failure: Causes, Symptoms, Treatments, Tests & More
https://www.webmd.com/fatty-liver-disease/digestive-diseases-liver-failure
The early symptoms of liver failure are often similar to those of other conditions. Because of this, liver failure may be tough to diagnose at first. Early symptoms include: Nausea, Loss of appetite, Fatigue, Diarrhea. […] As liver failure progresses, the symptoms become more serious, needing care right away. These symptoms include: Jaundice (yellowing of eyes and skin), Bleeding easily, Swollen belly, Mental confusion (known as hepatic encephalopathy), Sleepiness. […] These symptoms will appear in both chronic and acute liver failure. […] The causes of acute liver failure, when the liver fails rapidly, include: Acetaminophen overdose: Large doses can damage your liver or lead to failure. […] Liver failure can be acute (sudden) or chronic (ongoing). Signs of liver failure include yellowing of the skin and eyes (jaundice), swelling of the ankles and stomach, itchy skin, constant tiredness, and loss of appetite. You can have chronic liver failure for years with no symptoms.
#40 Content – Health Encyclopedia – University of Rochester Medical Center
https://www.urmc.rochester.edu/encyclopedia/content?contenttypeid=134&contentid=214
Acute liver failure is a rare condition. It happens when your liver suddenly starts to not work. […] If you have acute liver failure, you may have symptoms such as: Diarrhea, Discomfort on your right side, just below your ribs, Fatigue, Loss of appetite, Nausea. […] As the disease gets worse, you may also become confused and very sleepy. Other symptoms include: Bruising or bleeding easily, Jaundice (a yellowing of the skin and whites of the eyes), Vomiting blood, Buildup of fluid in your belly (abdomen). […] At first, acute liver failure causes fatigue, nausea, loss of appetite, discomfort on your right side just below your ribs, and diarrhea. As it gets worse, your skin may turn yellow, and you may become confused or comatose. […] Acute liver failure can happen in as little as 48 hours. Seek medical care at the first signs of trouble, such as: Fatigue, Nausea, Diarrhea, Discomfort in your right side, just below your ribs.
#41 Acute liver failure – Symptoms, diagnosis and treatment | BMJ Best Practice
https://bestpractice.bmj.com/topics/en-gb/1010
Acute liver failure is a rare, life-threatening, potentially reversible condition defined by jaundice, coagulopathy, and hepatic encephalopathy. […] Occurs in patients with no pre-existing liver disease and may result in severe liver impairment and rapid clinical deterioration. […] The aetiology and the interval from onset of jaundice to the development of encephalopathy have a significant impact on prognosis. […] ALF may be classified as hyperacute, acute, or subacute, depending on the interval from the onset of jaundice to the development of encephalopathy.
#42 Acute Liver Failure – LiverTox – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK548171/
Management of acute liver failure due to a medication requires careful attention to all details of medical management and is best done at a medical center at which liver transplantation is available. The first priority is to stop the implicated medication, but also to minimize any further liver damage.
#43 Acute Liver Failure | Conditions and Treatments | Center for Liver Disease & Transplantation | Columbia University Department of Surgery
https://columbiasurgery.org/conditions-and-treatments/acute-liver-failure
Due to its rapid development, acute liver failure is often fatal if not treated as soon as possible. However, with timely medical attention, its often possible to make a full recovery. […] Patients who develop acute liver failure after overdosing on acetaminophen, ingesting toxins, or contracting hepatitis and who begin a medication regimen soon enough (within 48 hours of signs or symptoms of the disease) typically are able to reverse the condition and regain their health.