LIVER FAILURE

What does liver failure mean?

Have you ever thought of an organ in your body capable of removing toxic substances, storing essential nutrients for growth and development, producing proteins and fatty acids involved in biological reactions and metabolism of drugs? This idea sounds truly incredible for one organ and you may wonder which organ this is.

The human liver is an organ capable of all these complex processes but it sequentially executes every process well mapped out in different chemical pathways.

When the liver fails, all these complex processes which are vital to living a normal life dwindle. The liver is very essential for the basic biological processes of every human, especially in the areas of digestion and removal of toxins. The inability of the liver, to perform the aforementioned duties, is what is termed as liver failure.

Before we can understand what liver failure is, it is best we know what the liver is.

WHERE IS THE LIVER? 

The liver is the largest internal organ of the body, weighing about 1 to 1.5kg; representing about 1.5 to 2.5% of the body’s total mass. The liver’s shape varies; from square and elongated, to lean and squat. It is located in the right upper region of the abdomen, below the rib cage. It is pressed against the diaphragm above it, projecting with a variable extent into the left upper region of the abdomen.

Blood is supplied to the liver via two pathways. Approximately 20% of blood flow rich in oxygen is from the hepatic (liver) artery, and 80% nutrient-rich blood, from the portal vein which arises from the stomach, intestines, pancreas and spleen.

DEFINITION

Liver failure is a life-threatening condition where the liver loses its ability to function normally.

The cause of damage to the liver could be as a result of viral infection, hepatotoxic drugs, chronic use of alcohol, acute bleeding or infection, pregnancy and other metabolic disorders.

Liver failure is classified into subtypes based on:

  • Onset.
  • Duration of the disease.

TYPES

The main types of liver failure or liver insufficiency include the following:

  • Acute Liver Failure:

This is an uncommon condition in which there is rapid deterioration of liver function resulting in coagulopathy (bleeding disorder) and encephalopathy (brain malfunction) in patients without any history of liver disease.

Most medical researchers question the use of “rapid” in defining acute liver failure due to the duration of onset, concerning changes in mental status and the disease in general. Generally, changes in mental status occur within 26 weeks of any hepatic symptoms. In addition, the onset of the acute liver failure is between 7-28 days.

  • Chronic Liver Failure:

Chronic liver failure is the progressive damage and regeneration of liver tissue. This long-term cycle of destruction and regeneration leads to cirrhosis (fibrotic inflammation of the liver) and usually lasts for a period of 6 months. Factors such as excessive alcohol intake, viral infections of the liver like Hepatitis B or C, as well as hereditary and metabolic disorders can cause chronic liver failure

  • Subacute Liver Failure:

Thus, can be described as an extension of Acute Liver Failure. In Subacute Liver Failure, there is an almost sudden deterioration of liver function just as with the Acute type, but the onset of Subacute Liver Failure is in 28-72 days

  • Acute on Chronic Liver Failure:

This presents in a person with a chronic liver disease developing features of Acute Liver Failure. This is mostly caused by alcohol misuse or viral infection. Patients with this condition require intensive medical care and rarely

 CAUSES AND RISKS OF LIVER FAILURE

  • Viral Infections:

Hepatitis A, B and C infections accounts for most liver failure cases, with Hepatitis B and C being more prevalent in the tropics due to drug abuse and sexual intercourse with infected persons. Other viral infections associated with liver failure are: Cytomegalovirus, hemorrhagic fever viruses, herpes simplex virus, paramyxovirus and Epstein-Barr virus.

  • Pregnancy:

Liver failure occurs in pregnancy, mostly due to increased fat deposition in the liver (acute fatty liver of pregnancy) and viral infection (Hepatitis E). There is greater prevalence of Hepatitis E infection in temperate and endemic areas like the Middle East, India, and Mexico. The HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome which is often associated with preeclampsia (hypertension in pregnancy) is often essential in diagnosis of liver failure in pregnancy.

  • Drug-Induced Hepatotoxicity:

This refers to injury to the liver caused by drugs and it is prevalent in most developed countries as access to drugs like Tylenol (Paracetamol) and Brufen (Ibuprofen) is relatively easier.

A study by CDC (Center of Disease Control and Prevention) in Hawaii, found out that dietary supplements used for weight loss and muscle gain caused liver injury. The study was able to identify 92 cases in all – patients with acute hepatitis of unknown cause, and among these patients, 51 reported using dietary supplements, 25 cases were hospitalized, 2 received liver transplants and 1 died.

Another prominent drug offender is acetaminophen (paracetamol) causing significant liver injury due to intentional or accidental overdose.
There is an increase in accidental overdose of paracetamol in the US per a recent study of acute liver failure in the US.
Chronic use of alcohol greatly increases one’s chances of being susceptible to drug-induced hepatoxicity, especially with paracetamol.

Prescription medications associated with liver failure include: antibiotics, antidepressants, antiepileptics, anesthetic agents, lipid-lowering medications, immunosuppressive agents, nonsteroidal anti-inflammatory agents (NSAIDS) and salicylates.

Illicit drugs associated with liver failure include: ecstasy and cocaine.
Known herbal medications associated with liver failure include: ginseng, pennyroyal oil, Teucrium polium, Chaparral or germander tea and kawakawa. However, it is advisable to refrain from use of herbal medications since most herbal medications are hepatotoxic.

  • Toxin-related hepatotoxicity:

This involves toxins mostly found in mushrooms and other fungal derivatives. Prevalence of intoxication of these mushroom toxins is mostly seen in temperate areas such as Europe and America. The toxins associated with liver failure include: cyanobacteria toxin, yellow phosphorus, organic solvents (carbon tetrachloride), Amanita phalloides mushroom toxin and Bacillus cereus toxin.

  • Vascular causes:

Vascular disorders within the liver may result in liver failure. These causes include: ischemic (poor blood flow) hepatitis, hepatic vein thrombosis (formation of a clot) e.g. Budd-Chiari syndrome, portal vein thrombosis and hepatic arterial thrombosis.

  • Metabolic diseases:

These diseases indirectly lead to the death of hepatocytes (liver cells). Metabolic diseases involved in liver failure are as follows: Alpha 1 – antitrypsin deficiency, fructose intolerance, galactosemia, lecithin-cholesterol acyltransferase deficiency, Reye’s syndrome, Tyrosinemia and Wilson’s disease.

  • Cancers:

    Abnormal growth of cells in the liver may impair liver function. Cancer growth tend to take up more nutrients, induce inflammation as wells as break through the liver structures, all of which compromise the liver’s integrity. Examples of some liver cancers are Hepatocellular carcinoma, Cholangiocarcinoma (cancer of the common bile duct) and Secondary metastatic cancers (Hepatic metastases from breast or lung cancer, lymphoma and leukemia)

SIGNS AND SYMPTOMS

There may be no symptoms initially or symptoms may manifest slowly. This normally depends on the effectiveness of the liver in performing its functions. Symptoms may worsen if the injury to liver is increased by the above the causes.

Symptoms include:

  • Loss of energy
  • Poor appetite and weight loss
  • Nausea (Sensation to vomit)
  • Abdominal pain
  • Small, red spider-like blood vessels on the skin (Spider navi)

Progressive symptoms as liver function worsens:

  • Fluid buildup in legs (pedal edema) and in the abdomen (ascites
  • Yellowish color of skin, mucous membranes or eyes (jaundice
  • Redness of palms (palmar erythema
  • Testicular atrophy (shrinking of testes) and breast swelling (gynecomastia) in men
  • Easy bruising and abnormal bleedin
  • Change in mental status presenting with confusion and problems in thinking
  • Somnolence (Sleepiness
  • Pale or clay-colored stools

 

DIAGNOSIS

Before any laboratory tests and imaging can be performed, to confirm if one suffers from liver failure, the health care provider would first begin a physical examination. The physical examination performed for patients with liver failure seeks to look for the following:

  • An enlarged liver or spleen
  • Excess breast tissue in males
  • Swollen abdomen as a result of excess fluid accumulated in the abdomen
  • Reddened palms
  • Red spider-like blood vessels on the skin
  • Small testicles
  • Widened veins in the abdominal wall
  • Yellowish coloration of eyes or skin (jaundice)

The laboratory tests performed to diagnose liver failure include:

  • Complete blood count (CBC)
  • Liver function tests
  • Serum bilirubin level
  • Serum ammonia level
  • Serum glucose level
  • Serum creatinine level
  • Serum phosphate level
  • Coagulation studies
  • Blood cultures
  • Viral serologies
  • Autoimmune markers
  • Drug screening

Other studies involved in the investigations of liver failure include:

  • Electroencephalography (EEG)
  • Intracranial pressure monitoring
  • Percutaneous or trans-jugular Liver biopsy

Imaging studies performed to diagnose liver failure include:

  • Doppler ultrasound of the Liver
  • Abdominal CT (Computed tomography) scan or MRI (Magnetic resonance imaging) without contrast.
  • Cranial CT scan

MANAGEMENT AND TREATMENT

In order to avoid injury or worsening injury to the liver, it is best to first begin with some mandatory lifestyle changes before commencing medications from your health care provider. The management and treatment of liver failure are as follows:

LIFESTYLE CHANGES:

  • Stop drinking alcohol, though it is difficult at first for chronic alcoholics, it provides a good prognosis in treating liver failure when alcohol intake is ceased.
  • Healthy diet, low in salt and rich in energy-giving foods. Eating such diets provides a boost in immunity against viral infections and reduces injury to the liver.
  • Seek vaccinations for viral infections such as influenza, hepatitis A, B and C and so on. This boosts one’s immunity against such viral infections, reducing damage and injury to the liver.
  • Seek advice from your health care provider concerning medications you take, including herbs and supplements and over-the-counter medications. This prevents issues with accidental overdose of medications, leading to drug-induced hepatotoxicity.

PHARMACOTHERAPY (MEDICATIONS)

Your healthcare provider may use the following medications management of liver failure:

  • Antidotes (Penicillin G, silibinin, activated charcoal, N-acetylcysteine)
  •  Osmotic diuretics (Mannitol)
  • Barbiturate agents (Pentobarbital, thiopental)
  • Benzodiazepines (Midazolam)
  • Anesthetic agents (Propofol)

SURGICAL TREATMENT

Treatment of liver failure may involve surgical means if your condition is deemed too serious or time sensitive. treatment includes:

  • Removal of fluid from the abdomen (paracentesis)
  • Placement of a trans-jugular intrahepatic portosystemic shunt (TIPS) to repair blood flow in the liver.
  • Liver transplant.

 COMPLICATIONS

Possible complications often seen in liver failure, include the following:

  • Bleeding disorders (Coagulopathy)
  • Buildup of fluid in the abdomen (ascites) and infection of the fluid (bacterial peritonitis)
  • Increased pressure in the blood vessels of the liver (portal hypertension)
  • Kidney failure (hepatorenal syndrome)
  • Liver cancer (hepatocellular carcinoma)
  • Mental confusion, change in level of consciousness or coma (hepatic encephalopathy)