Hepatitis and Acute Liver Failure

This Rare But Serious Condition Is Also Known as Fulminant Hepatitis

Hepatitis and the liver
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If you or a loved one has contracted viral hepatitis, you should be aware that acute liver failure is a rare but serious possible outcome of the infection. 

What Is Acute Liver Failure?

Acute liver failure is a rapidly developing medical emergency. The condition is also referred to as a fulminant hepatic failure, acute hepatic necrosis, fulminant hepatic necrosis, and fulminant hepatitis.

It occurs when cells of the liver are injured so quickly that the organ cannot repair itself fast enough. Parts of the liver die or begin to no longer work. Such an event can cause the liver to stop working altogether, resulting in problems in other areas of the body. 

Because the liver is such a vital part of the body, when it is damaged, other organs are affected, too. The brain is one of the more important organs affected during liver failure, and injury to the brain results in a condition called encephalopathy.

Liver failure is generally considered acute rather than chronic when the onset of illness occurs within fewer than 26 weeks. 

Symptoms of Acute Liver Failure

Before a physician can diagnose fulminant hepatitis, the patient must show signs of encephalopathy, a disease of the brain. Key symptoms are:

  • Anxiety
  • Confusion
  • Change in behavior
  • Change in alertness
  • Difficulty working through mental processes
  • Disorientation

These symptoms can lead to coma and even death if the liver failure does not reverse.

Other symptoms of acute liver failure include: 

  • Fatigue/malaise
  • Lethargy
  • Anorexia
  • Nausea and/or vomiting
  • Right upper quadrant pain
  • Itching
  • Jaundice
  • Abdominal swelling

Acute liver failure is diagnosed based on abnormalities on liver tests (such as a bilirubin level test), hepatic encephalopathy and prolonged prothrombin time, which the amount of time it takes for blood plasma to clot.

Transaminases and ammonia levels will also be elevated, and it is not uncommon for there to be acute kidney injury.

Causes of Acute Liver Failure

Acute liver failure is one of the most serious complications of viral hepatitis infection. In fact, every physician has this concern in their mind when treating patients with acute viral hepatitis.

Acute liver failure is very rare. When it does occur, it's most common in hepatitis A and hepatitis B infection. Even then, fewer than 1% of people with hepatitis B infection, and an even smaller percentage of people with hepatitis A, will develop fulminant hepatitis.

Hepatitis C generally is not associated with acute liver failure unless there is a co-infection with hepatitis B. Likewise infection with hepatitis D along with hepatitis B may cause acute liver failure. Hepatitis E is a significant cause in some countries outside the United States such as Russia and Mexico, and is associated with a significant mortality rate in pregnant women.

HSV 1 and 2 rarely cause acute liver failure.

Another significant cause of acute liver failure, especially in the U.S., is acetaminophen toxicity. Acetaminophen, commonly known as Tylenol, is a pain-relieving drug similar to aspirin and can be purchased without a prescription. Too much of this drug will harm the liver and could lead to liver failure. People who frequently drink heavy amounts of alcohol and take too much acetaminophen might be at increased risk for acute liver failure.

There are many other possible causes of acute liver failure. In the United States, drug induced liver injury is the most common cause. (In some other place in the world, hepatitis is the most common). Some pregnancy related illnesses, autoimmune disease, some herbs, cancer infiltrating the liver, sepsis, thrombotic disease and Budd-Chiari syndrome are other potential causes.

Treatment and Prognosis

People with acute liver failure should be treated in a critical care setting in a hospital that does liver transplants.

The objective is to keep the patient alive long enough to give the body's liver time to repair itself, or until the patient can have a liver transplant. Unfortunately, liver transplants are not medically advisable for everyone and sometimes there are no livers available to transplant.

In acute liver failure caused by viral hepatitis, antiviral therapy may help avoid the need for a liver transplant.

A 2016 review of 31 centers found a 21-day survival rate of 56% for people treated without transplantation and of 96% for those receiving a transplant. Both statistics represent a significant improvement compared with survival rates 8 years earlier.

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Article Sources

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  1. Murali AR, Menon KVN. Acute liver failure. Cleveland Clinic Center for Continuing Education. 2017.

  2. Rajaram P, Subramanian R. Acute liver failure. Semin Respir Crit Care Med. 2018;39(5):513-522. doi:10.1055/s-0038-1673372

  3. Reuben A, Tillman H, Fontana RJ, et al. Outcomes in adults with acute liver failure between 1998 and 2013: An observational cohort study. Ann Intern Med. 2016;164(11):724-32. doi:10.7326/M15-2211

Additional Reading

  • Dienstag JL. Acute Viral Hepatitis. Harrison's Principles of Internal Medicine, 17e. New York: McGraw-Hill, 2008.

  • Fontana RJ. Acute Liver Failure. Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8e. Philadelphia: Elsevier, 2006.