Definition and Overview

The liver is the body’s largest and heaviest internal organ. Located on the right side of the belly, it works with other internal organs, including the pancreas and intestines, to digest, absorb, and process food. Aside from producing bile, a substance that the body uses to digest fats, the liver is also responsible for detoxifying blood by eliminating harmful substances such as drugs and alcohol.

Hepatic failure, which can be either acute or chronic, is a life-threatening condition characterised by the deterioration of liver function. Acute liver failure is characterised by the sudden or rapid loss of liver function usually due to acetaminophen overdose or mushroom poisoning. It can occur within just weeks or even days and commonly affects people with no pre-existing liver disease. Chronic liver failure, on the other hand, develops more slowly, often taking months or even years before it produces any noticeable symptoms. It is characterised by the progressive destruction of the liver usually due to cirrhosis, a liver condition that occurs when normal liver tissue is replaced by scar tissue that prevents the liver from functioning properly.

Causes of Condition

Aside from acetaminophen overdose and cirrhosis, liver failure can also be caused by:

  • Acute fatty liver of pregnancy

  • Biliary atresia, which is the common cause of cirrhosis in babies

  • Biliary cirrhosis

  • Certain autoimmune diseases

  • Chronic liver congestion

  • Excessive alcohol consumption

  • Genetics - People whose either or both parents are suffering from a genetic liver disease are at risk of developing acute hepatic failure

  • Metabolic diseases

  • Toxins

  • Viral hepatitis/infections

Key Symptoms

When the liver is damaged beyond repair, it is unable to remove waste from the body, produce bile, and store sugar that the body needs for energy. As a result, patients experience the following symptoms:

  • Abdominal bleeding

  • Abdominal pain associated with distention

  • Altered sleep/wake cycle

  • Bruising or bleeding easily

  • Confusion

  • Fatigue

  • Itching

  • Lack of concentration

  • Low sodium levels

  • Nausea

Unless the condition is promptly diagnosed and treated, patients are at risk of the following complications:

  • Enlarged spleen

  • Fluid buildup in the legs and abdomen

  • Kidney injury

  • Portal hypertension

  • Respiratory and urinary tract infections

  • Decreased mental function

  • Swelling of the brain

  • Bacteria and fungal infections

Who to See and Types of Treatments Available

Liver failure is diagnosed with the following tests and procedures:

  • Blood tests

  • Liver function tests

  • Liver biopsy - For this procedure, a needle is used to obtain a small tissue sample from the liver. The sample is then checked under a microscope to confirm the extent of liver damage.

  • Imaging tests - Magnetic resonance imaging (MRI), ultrasound, endoscopy, and computed tomography (CT) scan may be carried out to obtain detailed pictures of the liver and surrounding structures including other organs, blood vessels, and tissues.

  • Mental health assessment

Liver failure patients are often admitted to the intensive care unit (ICU) especially if they show signs of encephalopathy (a general term used to describe brain malfunction, damage or disease) and circulatory dysfunction. They are treated by a multidisciplinary team of doctors that includes neurologists, haematologists, infectious diseases specialists, gastroenterologists, and intensive care specialists. These doctors focus on controlling signs and symptoms of the condition as well as preventing additional complications from developing. In doing so, they may need to perform some or all of the following:

  • Protect the airway of comatose patients through intubation or insertion of nasogastric tube

  • Provide low doses of short-acting benzodiazepines to patients showing signs of encephalopathy

  • Prescribe medications (such as mannitol and barbiturate agents) to manage intracranial hypertension

  • Administer fluid resuscitation for patients suffering from severe gastrointestinal blood loss

  • If acute liver failure is caused by acetaminophen overdose or mushroom poisoning, doctors provide medications that can reverse the effects of the toxin.

Liver transplantation is the definitive treatment for the condition. It is a surgical procedure to replace a severely damaged liver with a healthy liver from a living or deceased donor.

Patients who require a liver transplant are referred to a transplant centre where they are evaluated to determine their eligibility. To qualify, candidates for liver transplant must be healthy enough to undergo surgery and are willing and able to take life-long post-transplant medications.

Patients are scored based on Model for End-Stage Cancer Liver Disease or MELD. The score, which can be between six and forty, estimates the patient’s risk of dying in the next three months unless he undergoes a liver transplant. Those with higher MELD scores are prioritised. As donated livers are scarce, some patients wait for months or even years before they undergo liver transplantation. Patients waiting for a new liver are closely monitored for complications of liver failure and are often hospitalised.

Once a new liver becomes available, the recipient is asked to come to the hospital immediately for transplantation. The procedure is performed under general anaesthesia and can last up to twelve hours depending on the patient’s unique circumstances. For the procedure, the surgeon will make a long incision in the abdomen to access the damaged liver, which is then disconnected from the vessels that supply blood to it and from the bile ducts. The damaged liver is then removed and replaced with the donor liver, which is then attached to the blood vessels and bile ducts.

Patients have to stay in the ICU for a few days after the operation and then to a regular hospital room for additional one to two weeks for close monitoring. They are expected to return to their work after a few months and to fully recover after six months. They are required to take immunosuppressants for the rest of their lives to keep their immune system from attacking their new liver.

The prognosis for liver transplant patients is generally good. Up to 70% of them live for at least five years with minimal to zero complications.

References:

  • Feldman M, et al. Liver transplantation. In: Sleisenger & Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 10th ed. Philadelphia, Pa.: Saunders; 2016. https://www.clinicalkey.com.

  • Stravitz RT, Kramer AH, Davern T, et al, for the Acute Liver Failure Study Group. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med. 2007 Nov. 35 (11):2498-508.

  • Demetriou AA, Brown RS Jr, Busuttil RW, et al. Prospective, randomized, multicenter, controlled trial of a bioartificial liver in treating acute liver failure. Ann Surg. 2004 May. 239 (5):660-7; discussion 667-70.

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