13. The Acute Liver Failure Patient

  1. John N. Plevris MD, PhD, FRCPE, FEBGH1 and
  2. Colin W. Howden MD, FRCP (Glasg.), FACP, AGAF, FACG2
  1. Neil C. Henderson BMS c(Hons), MBChB (Hons), MSc, PhD, MD, FRCP(Ed) and
  2. Kenneth J. Simpson MBChB, MD, PhD, FRCPE

Published Online: 29 NOV 2011

DOI: 10.1002/9781444346381.ch13

Problem-Based Approach to Gastroenterology and Hepatology

Problem-Based Approach to Gastroenterology and Hepatology

How to Cite

Henderson, N. C. and Simpson, K. J. (2012) The Acute Liver Failure Patient, in Problem-Based Approach to Gastroenterology and Hepatology (eds J. N. Plevris and C. W. Howden), Wiley-Blackwell, Oxford, UK. doi: 10.1002/9781444346381.ch13

Editor Information

  1. 1

    Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK

  2. 2

    Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Author Information

  1. Centre for Liver and Digestive Disorders, The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK

Publication History

  1. Published Online: 29 NOV 2011
  2. Published Print: 17 JAN 2012

ISBN Information

Print ISBN: 9781405182270

Online ISBN: 9781444346381



  • acute liver failure;
  • hepatic encephalopathy;
  • paracetamol;
  • acetaminophen;
  • Wilson's disease;
  • viral hepatitis;
  • liver transplantation


Acute liver failure (ALF) is an uncommon clinical condition associated with massive liver injury and the development of hepatic encephalopathy in patients with previously normal liver function and architecture. This condition requires early recognition and discussion with or transfer to a unit that can assess for and provide liver transplantation. Supportive and specific therapy may also be appropriate. The most common cause for ALF in the western world is paracetamol (acetaminophen) poisoning, either as a deliberate suicide attempt or after inadvertent ingestion of excessive amounts. A case of paracetamol-induced ALF is discussed in case 1. Non-paracetamol causes of ALF include non-A–E or seronegative hepatitis, acute viral hepatitis, idiosyncratic drug reactions, and pregnancy-associated causes such as acute fatty liver of pregnancy and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). Less common causes such as Wilson's disease are worthy of specific mention; Wilson's disease produces a characteristic clinical picture (discussed in case 2) that may facilitate early recognition and specific therapy with penicillamine. If introduced early enough, before the development of hepatic encephalopathy, penicillamine may avoid the need for emergency liver transplantation. Non-paracetamol causes of ALF often develop clinically over longer periods of time, compared with paracetamol-induced ALF. Differentiation of ALF from decompensated chronic liver disease in such cases can be difficult (discussed in case 3). Emergency liver transplantation is life saving in selected cases of ALF, but this requires accurate prognostication. Many patients are treated medically with multiorgan support. Both transplantation and multiorgan support are discussed with reference to the cases presented.