Common Causes & Symptoms of Acute Liver Failure: You Need to Know

Acute liver failure (ALF) is a rare but life-threatening condition characterized by the sudden loss of liver function in individuals with no prior liver disease. Acute liver failure is less common than chronic liver failure, but life-threatening. It can cause internal bleeding and increased pressure in the brain. Acute liver failure can be reversed with the help of medical treatment and lifestyle changes.

However, in some cases, doctors advise a liver transplant. The main signs of acute liver failure are jaundice, fatigue, and mild confusion. In this article, we explore the symptoms and primary causes of acute liver failure, highlighting how these factors impact liver health.

Primary Causes of Acute Liver Failure

There are several causes of acute liver failure. While high doses of drugs containing acetaminophen can affect the way the liver functions, other factors, such as viruses, immune system dysfunction, alcohol and metabolic conditions also cause acute liver failure. As symptoms of acute liver failure are rarely observed in the early stages, the condition gets detected only in its later stage.

Furthermore, as acute liver failure is a rare condition even in patients with no known pre-existing liver condition, it carries a high mortality rate. It is, therefore, necessary to understand the causes of acute liver failure, its symptoms and when to consult the doctor.

1. Drug-Induced Liver Injury

The liver helps break down medications and filters out toxins from the bloodstream. But in some people, this process is slower, which results in liver damage due to toxin build-up. While drugs are made to heal, some drugs, in high doses, are known to cause acute liver disease. Drugs prescribed for pain and fever and which contain acetaminophen cause liver injury, especially when taken in large doses over time.

The symptoms of drug-induced liver injury are similar to other liver conditions. These include jaundice, fatigue, abdominal pain, lack of appetite, fever, itchy skin, and dark-coloured urine. In some people, damage to the liver due to drugs can be mild and temporary. But in others, it can lead to acute liver disease. People with drug-induced liver injury are more likely to need a liver transplant.

Introduction To Drug-Induced Liver Injury

Drug-induced liver injury occurs due to certain medications. Acute liver failure is an adverse reaction to drugs. It can also occur due to genetic or environmental factors that make some people prone to the condition.

Common Medications Associated With Liver Failure

Some prescription and over-the-counter medications that cause drug-induced liver failure are:

Over-The-Counter Medications:

• Acetaminophen (Paracetamol): Dolo, Himol
• Non-steroidal anti-inflammatory drugs (NSAIDs): Aspirin, Ibuprofen, Diclofenac, Naproxen

Prescription Medications:

• Antibiotics
• Antifungal drugs
• Arthritis drugs
• Antiviral drugs for HIV infection
• Allopurinol for Gout
• Antiseizure drugs
• Birth control pills
• Cancer medications
• Erythromycin
• Halothane (a type of anaesthesia)
• Statins
• Steroids
• Niacin

Factors Influencing Drug-Induced Liver Injury

Dosage And Duration Of Medication Use: While many types of drugs can cause acute liver disease, drugs that contain acetaminophen are known to cause acute liver disease. Common pain killers and fever medications like paracetamol and ibuprofen taken daily over a long period of time can damage the liver. Following doctor's prescriptions is therefore crucial.

Individual Susceptibility And Genetic Factors: Some people are more susceptible to drug-induced liver injury due to factors, such as,

• Age
• Gender (women are prone to drug-induced liver injury)
• Weight
• Race (those of African American descent)
• Excessive alcohol consumption over a long period of time
• Mixing alcohol with drugs
• Genes

2. Viral Hepatitis

Hepatitis is the inflammation of the liver. Viral hepatitis is caused by a virus. It can be acute and last for a few months or chronic and last for more than six months. Viral hepatitis is contagious and can spread from person to person. Some types of this condition also spread through sexual contact. Several viruses cause hepatitis.

Some types of viral hepatitis are:

• Hepatitis A: Hepatitis A is a viral infection that affects the liver. It causes acute liver inflammation. This infection lasts for a couple of months. Its symptoms are mild to severe illness. While hepatitis A does not cause chronic liver disease or lasting liver damage, it can cause acute liver failure.
• Hepatitis B: Hepatitis B is a virus that can infect the liver and cause inflammation. It is an acute infection that lasts for a short period. It is a common liver infection that spreads through bodily fluids. In some people, it may turn chronic and damage the liver seriously. It can be treated with antiviral medications, but it is not curable.
• Hepatitis C: Hepatitis C is a virus that causes chronic liver inflammation. It transmits through contact with blood. It spreads through shared needles while injecting intravenous drugs. Hepatitis C is likely to stay in the body for a long period. Chronic hepatitis C infection can cause serious liver damage and liver failure.
• Other Viral Causes of Acute Liver Failure: Besides hepatitis A, B and C, other viruses can also cause acute liver failure. These are:

• Epstein-Barr virus
• Cytomegalovirus
• Herpes simplex virus

3. Autoimmune Hepatitis

Autoimmune hepatitis occurs when the immune system attacks the liver. It is a chronic inflammation of the liver which may cause liver cirrhosis over time. Medical treatment can help the inflammation and prevent complications. However, people do not experience its symptoms in the early stages. Autoimmune hepatitis is a rare condition. People with other autoimmune diseases are more susceptible to autoimmune hepatitis. Some of its symptoms include swollen liver, abdominal pain, fatigue, skin rash, itchy skin, jaundice, loss of appetite, easy bruising and bleeding, spider angioma, confusion, and drowsiness.

4. Toxins and Poisons

Exposure to industrial chemicals, toxic mushrooms (such as Amanita phalloides), or herbal supplements containing hepatotoxic compounds can cause liver damage and acute failure.

5. Ischemic Hepatitis

A sudden reduction in blood flow to the liver, often due to cardiac arrest, severe hypotension, or shock, can result in ischemic hepatitis, which may progress to acute liver failure.

6. Metabolic Diseases

Inherited metabolic disorders such as Wilson's disease (characterized by copper accumulation in the liver) or Reye’s syndrome in children can precipitate acute liver failure.

7. Fatty Liver of Pregnancy

Rarely, acute fatty liver of pregnancy (AFLP) can occur in the third trimester, posing a severe risk to both the mother and fetus. It demands immediate medical intervention.

8. Sepsis and Infections

Severe systemic infections or sepsis can overwhelm the liver, impairing its ability to detoxify the blood and leading to acute liver failure.

9. Unknown Causes (Idiopathic)

In some cases, the underlying cause of acute liver failure remains unidentified despite thorough investigation.

Recognizing the Symptoms of Acute Liver Failure

Early symptoms may include nausea, fatigue, and jaundice. As the condition progresses, confusion, bleeding tendencies, and even coma may occur. Immediate medical attention is critical for survival. Common and severe symptoms include:

• Jaundice: Yellowing of the skin and eyes due to a buildup of bilirubin in the blood.
• Abdominal Pain: Discomfort or pain in the upper right side of the abdomen.
• Confusion or Disorientation: Mental confusion, difficulty concentrating, or altered levels of consciousness (hepatic encephalopathy).
• Fatigue: Extreme tiredness and weakness, often unrelieved by rest.
• Nausea and Vomiting: Persistent feelings of nausea accompanied by vomiting.
• Swelling: Swelling in the abdomen (ascites) or legs due to fluid retention.
• Bleeding and Bruising: Easy bruising or prolonged bleeding due to impaired blood clotting.
• Reduced Urine Output: Decreased production of urine, indicating kidney dysfunction often associated with liver failure.

Diagnosis of Acute Liver Failure

Diagnosing acute liver failure involves a combination of medical history, physical examination, and diagnostic tests to confirm the condition and identify its underlying cause.

• Blood Tests: Measures liver enzymes (ALT, AST), bilirubin, and clotting time (INR) to assess liver function.
• Imaging Studies: Ultrasound, CT, or MRI scans help visualize the liver structure and detect abnormalities.
• Viral Hepatitis Panel: Detects the presence of hepatitis viruses (A, B, C, or E) as potential causes.
• Toxin Screening: Identifies toxins or drugs that may have contributed to liver failure.
• Autoimmune Tests: Detects markers of autoimmune hepatitis, such as antinuclear antibodies (ANA).
• Liver Biopsy: Invasive procedure used in select cases to confirm the diagnosis and extent of liver damage.
• Ammonia Levels: High ammonia levels in the blood may indicate hepatic encephalopathy.
• Kidney Function Tests: Assesses associated renal dysfunction often present in acute liver failure.

Acute Liver Failure Treatment Options and Management

A high dose of corticosteroids, usually Prednisone, is the main line of acute liver failure treatment to help relieve the inflammation and suppress the immune system. Doctors may also prescribe an immunosuppressant along with the steroids. Immunosuppressants are long-term therapy to keep the immune system from becoming overactive. Besides medications, avoiding alcohol and following a healthy diet for the liver with low in sugar and saturated fats to maintain a healthy weight, is advised. Doctors also recommend vitamin supplements and vaccines to protect against infections.

Alcohol-Related Liver Disease

Alcohol is the primary cause of liver disease. Drinking excessive alcohol increases the risk of liver disease and liver cancer. The liver breaks down alcohol, but the harmful chemicals produced in this process damage the liver cells. Long-term liver damage due to alcohol leads to scarring and cirrhosis. The risk of alcohol-related liver disease increases in people with a pre-existing liver condition or those who are overweight, and have a family history of liver disease.

Alcohol-related liver disease (ARLD) has no medical treatment. The only treatment is to quit drinking. If the liver has stopped functioning completely, doctors advise a liver transplant. Complications of ARLD include internal bleeding, toxic build-up in the brain, fluid accumulation in the abdomen, liver cancer, and infections.

• Alcohol Hepatitis: Prolonged alcohol consumption leads to alcoholic hepatitis. Drinking large amounts of alcohol in a short time also causes alcohol hepatitis. The condition can not be reversed and is a life-threatening illness.

• Alcoholic Cirrhosis: Alcoholic cirrhosis is a stage where the liver is seriously scarred. The symptoms of ARLD may not be obvious at this stage. Quitting alcohol can prevent further damage and improve the chances of recovery and better quality of life.

• Alcohol-Related Acute Liver Failure: Consuming large quantities of alcohol can lead to a build-up of fats in the liver cells. It leads to an enlarged liver, which is the most prevalent alcohol-related liver problem. People with alcohol-related liver disease are at a greater risk of liver cancer.

• Effects of Long-Term Alcohol Abuse and Cessation: Consuming excessive alcohol can cause chronic diseases, such as heart disease, high blood pressure, stroke, liver disease, digestive problems, and cancer of the liver, colon cancer, rectum cancer, breast cancer, esophagus cancer, mouth cancer, and throat cancer. Alcohol cessation can cause withdrawal symptoms. These can be emotional and physical. Symptoms range from mild anxiety, hallucinations, seizures, fatigue, nausea, increased heart rate, insomnia, high blood pressure, and confusion.

Supportive Management

• Nutritional Support: Providing intravenous nutrition to prevent malnourishment.
• Fluid Management: Balancing fluid intake to avoid dehydration or fluid overload.
• Infection Control: Administering antibiotics or antifungals to prevent or treat infections.

Lifestyle and Follow-Up

• Abstinence from Alcohol: Avoiding alcohol to reduce further liver strain.
• Monitoring and Rehabilitation: Regular follow-ups and lifestyle modifications to aid recovery.

Frequently Asked Questions

1. How does Acetaminophen Overdose Lead to Acute Liver Failure?

Usually, moderate doses of acetaminophen are removed by the liver through the urine. However, more than the recommended dose overloads the liver and affects its ability to process the drug.

2. What are the Treatment Options for Wilson's Disease and Hemochromatosis?

To treat Wilson's disease, doctors prescribe chelating agents that bind the copper and help the organs to release the copper into the bloodstream. The kidneys filter the copper and release it through the urine. Hemochromatosis is too much iron in the body. Doctors treat hemochromatosis by removing blood from the body regularly to lower iron levels. This process is called phlebotomy and is conducted based on the patient's age, health and the intensity of iron overload.

3. What are the Long-Term Effects of Alcohol-Related Liver Disease?

Excessive drinking leads to alcohol-related liver disease. It can cause permanent liver scarring, loss of liver function, high blood pressure in the blood vessels, and loss of brain function due to toxic build-up in the blood.

4. How is Acute Liver Failure Different from Chronic Liver Disease?

In acute liver failure, patients do not have a preexisting liver condition. Its common causes are viral hepatitis, acetaminophen toxicity, drugs and toxins, and sepsis. It occurs quickly, within days or weeks. Chronic liver failure occurs due to alcohol abuse, hepatitis B and C, and non-alcoholic fatty liver disease. It develops over time.

5. Are Certain Populations More Susceptible to Acute Liver Failure?

People with diseases and infections such as hepatitis, Wilson's disease, herpes simplex virus and those who consume high doses of acetaminophen are more susceptible to acute liver disease.

6. How long does recovery take after treatment?

Recovery depends on the severity and cause of acute liver failure. Some patients recover fully within weeks, while others may require long-term care.

7. Can acute liver failure recur?

If the underlying cause is not resolved or managed, there is a risk of recurrence. Proper treatment and lifestyle changes are vital to prevention.

8. Who treats acute liver failure disease?

Acute liver failure is treated by a multidisciplinary team of healthcare professionals, including hepatologists (liver specialists), critical care physicians, surgeons (for liver transplants), and nutritionists. These experts work together in specialized medical centers equipped to handle liver-related emergencies.