⚠️ Acute Liver Disease ≠ Acute Liver Failure
Acute liver disease can range from mild hepatocellular injury to life-threatening ALF. ALF is defined by impaired synthetic function (coagulopathy, encephalopathy) in a patient without pre-existing cirrhosis.

🩺 Acute Liver Disease & Acute Liver Failure – UK Guidelines

1. Classification of Acute Liver Failure

Type	Jaundice → Encephalopathy	Common Causes	Key Features
Hyperacute	< 1 week	💊 Paracetamol, viral hepatitis A/B/E	High risk of cerebral oedema, rapid deterioration
Acute	1 week – 1 month	Drugs, viruses, autoimmune	Cerebral oedema possible, variable prognosis
Subacute	1 – 3 months	Drugs, viruses, idiopathic	Lower cerebral oedema risk, slower progression

2. Causes of Acute Liver Disease & ALF

🦠 Infectious: HAV–E, HBV, HCV, HDV, EBV, CMV, HSV, VZV, adenovirus, dengue, SARS-CoV-2
💊 Drugs/Toxins: Paracetamol (dose-dependent), antibiotics, anticonvulsants, NSAIDs, statins, herbal remedies; Amanita mushroom 🍄, carbon tetrachloride
🍷 Alcoholic hepatitis
🛡️ Autoimmune hepatitis
🧬 Metabolic: NAFLD, Wilson’s disease, haemochromatosis, alpha-1 antitrypsin deficiency
⚠️ Pregnancy-related: HELLP, acute fatty liver of pregnancy, preeclampsia
🩸 Vascular/Ischaemic: Budd–Chiari, cardiogenic shock, heatstroke, sinusoidal obstruction
🐀 Others: Leptospirosis, yellow fever, Reye’s syndrome, graft non-function post-transplant

3. Clinical Features: Jaundice Encephalopathy Coagulopathy

📖 History: Recent drug/toxin exposure, travel, infection
🤢 Symptoms: Jaundice, nausea, vomiting, bleeding, hypoglycaemia
🧠 Encephalopathy: Asterixis, confusion, fetor hepaticus, coma (Grades 1–4)
RUQ pain, hepatomegaly, pale stools, dark urine
Stigmata of chronic liver disease usually absent

🩺 Clinical Signs: Acute vs Chronic Liver Failure

Feature	Acute Liver Failure ⚡	Chronic Liver Disease 🕰️
Onset ⏱️	Rapid (days–weeks)	Insidious (months–years)
Encephalopathy 🧠	Early, progresses quickly: confusion → coma (Grades 1–4)	Late; usually precipitated by infection, GI bleed, or medications
Jaundice 🟡	Sudden, often marked, dark urine 💛	Gradual, persistent, mild initially
Coagulopathy 🩸	Severe, INR ↑ early; bleeding risk high	Variable; chronic compensated coagulopathy possible
Ascites 💧	Rare at presentation, may develop later	Common, recurrent
Splenomegaly 🌳	Usually absent	Common, due to portal hypertension
Spider Naevi / Palmar Erythema 🕷️	Rare	Common, classic stigmata
Caput Medusae / Varices 🐍	Rare	Common, may cause GI bleeding 🍽️
Muscle Wasting 💪	Usually absent	Common, due to chronic malnutrition and catabolism
Other Stigmata ⚕️	Minimal; mainly jaundice-related features	Gynecomastia 👨‍🦰, testicular atrophy, nail changes 💅, palmar erythema ✋, asterixis ✋, bruising 🟣

💡 Clinical Tip: Acute liver failure ⚡ presents dramatically with early coagulopathy 🩸 and encephalopathy 🧠, often before stigmata of chronic disease develop. Chronic liver disease 🕰️ evolves slowly, with portal hypertension signs 🌳💧 and systemic manifestations 💪.

4. Investigations – Hepatocellular Injury vs Synthetic Function

Parameter	Findings / Interpretation	Clinical Tip
AST / ALT	>1000 → paracetamol, viral, ischaemic hepatitis 100–500 → alcohol, NAFLD, chronic hepatitis	High alone ≠ failure; check synthetic markers
ALP / GGT	Raised in cholestasis, drug-induced injury, obstruction, malignancy	Compare with bilirubin to assess cholestatic pattern
INR / Albumin	Prolonged INR or low albumin = impaired synthetic function → ALF risk	Essential for distinguishing simple injury from ALF
Other Labs	FBC, U&E, viral serology, autoimmune screen, copper/iron studies, pregnancy test, HIV	Tailor to history and suspected aetiology
Imaging	Ultrasound ± Doppler: obstruction, Budd–Chiari, steatosis, hepatomegaly	Rapid bedside imaging for vascular or obstructive causes

5. Management

🛌 Admit to HDU/ICU; early hepatology involvement
🔄 ABC support: airway, oxygen, fluids
🍬 Hypoglycaemia: IV dextrose
🩸 Coagulopathy: Vitamin K ± FFP / platelets if bleeding or prior to invasive procedures
💩 Encephalopathy: Lactulose, maintain 2–3 soft stools/day
🧠 ICP precautions: head up 20°, avoid hypotension/hypoxia, mannitol if cerebral oedema
🚑 Early transplant referral for ALF with encephalopathy + coagulopathy (King’s College criteria)

6. Cause-Specific Therapy

💊 Paracetamol overdose → IV N-acetylcysteine (NAC)
🛡️ Autoimmune hepatitis → corticosteroids (infection excluded)
🍄 Amanita mushroom → IV Penicillin G ± silymarin; urgent transplant evaluation
🤰 Pregnancy-related → prompt delivery if HELLP or acute fatty liver
🧬 Wilson’s disease → chelation or urgent transplant
🦠 Viral hepatitis → supportive ± antivirals (HSV/HBV)
🩸 Budd–Chiari → anticoagulation, thrombolysis, shunt, or transplant

7. Complications

⚡ Hypoglycaemia
🩸 Coagulopathy & bleeding
🧠 Cerebral oedema → herniation risk
🧬 Infection / sepsis
⛑️ Hepatorenal syndrome

8. References

💡 Clinical Pearl: Always assess synthetic function (INR, albumin) to distinguish hepatocellular injury from life-threatening ALF. AST/ALT >1000? Consider paracetamol, viral hepatitis, or ischaemic causes. Early recognition + supportive care saves lives.

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Acute Liver Disease & Acute Liver Failure (NICE)