Acute Liver Failure- Gastroenterology

Acute liver failure is a condition that develops when liver function rapidly deteriorates and fails. This happens most often because of a virus that causes hepatitis. Taking excess amounts of certain drugs like acetaminophen or drinking too much alcohol can also cause hepatitis. Acute liver failure is also called fulminant liver failure, and it needs to be treated rapidly because complications include respiratory, cardiovascular, and renal failure. There are also often neurological problems with the build-up of toxins leading to encephalopathy, where brain function is impacted. Liver failure can quickly lead to death without proper management.

Who treats acute liver failure?

The doctors who specialize in liver disorders are known as hepatologists. These doctors also treat conditions of the pancreas and gallbladder. Transplant surgeons are involved in liver transplants.

Diagnosis for treatment

Diagnosis of liver failure and assessing the severity of the condition are important in helping a doctor decide on the best course of treatment for a patient.

Diagnostic methods include the following:

• A blood test of clotting ability: This is the international normalized ratio (INR) test. A value of greater than 1.5 indicates liver damage.
• A complete blood cell count (CBC) is done, and electrolytes are measured.
• Liver enzyme levels are tested in a blood test. The levels of both aspartate aminotransferase (AST) level and alanine aminotransferase (ALT) are higher than normal in patients with liver problems. The AST will also be higher than the ALT.
• Blood tests of IgM antibodies. These substances are elevated in case of liver problems caused by viral infections.
• Imaging tests: MRI and CT scans are useful in showing abnormalities in the liver, such as tumors or bile duct problems.
• Liver biopsy: Removing a small piece of the liver can help doctors see why a person is in  liver failure. However, this may be too dangerous if liver failure is in an advanced stage because it can cause bleeding.

Treatment options for acute liver failure are described below.

Supportive therapy

Supportive therapy is important in patients with liver failure. The following methods are used:

• Intensive care unit nursing: Patients are carefully monitored.
• Intravenous glucose nutrition: Specifically, IV glucose is given to combat low blood sugar, which often occurs in these patients.
• Enteral protein nutrition: About 1.0 to 1.5 g of protein is given per kilogram, enterally, per day. The amount of protein is adjusted depending on ammonia levels in the patients.

Methods to detoxify the liver

• Intravenous acetylcysteine: This can be used in patients who have taken too much acetaminophen, causing liver damage. However, this is only effective in patients who have low-grade encephalopathy.

Methods to remove excess nitrogen and ammonia

Patients with liver failure have an accumulation of ammonia, a nitrogenous product that needs to be eliminated from the body. Ways to eliminate excess nitrogen include

• Enemas: Enemas are used to clean the bowels out and remove some nitrogen.
• Lactulose: This chemical acts by pulling ammonia out of the bloodstream and helps transport it to the large intestine for later elimination.
• Sodium Benzoate or L-Ornithine Phenyl Acetate (LOPA) and l-Ornithine-L-Aspartate (LOLA). are substances that help to decrease ammonia in the blood via various chemical pathways.

Extracorporeal Liver Support 

There are machines called extracorporeal liver-assist devices that are used to help when the liver is failing. This method is often used to try and stabilize a patient before getting a liver transplant. It can also help liver regeneration. Heparin is used in these different devices to prevent blood clots from forming.

The types of devices used are as follows:

Bioartificial devices

These include liver cells from humans or pigs, which help provide the functions of detoxification and the anabolic functions of making certain molecules (also a liver function). The common device used is called the HepatAssist.

• Patients first have plasmapheresis, where blood is removed via a catheter or needle.
• The plasma that is collected then moves through a filter membrane of the device on which there are hepatocytes.
• The hepatocytes perform the usual liver functions for the patient.
• Plasma is passed through charcoal columns and an oxygenator.
• A pump is also used, and plasma is returned back to the patient.

Nonbiologic dialysis-based systems

A molecular Absorbent Recirculating System (MARS) is the most commonly used device. This provides a way to remove toxins and filter the blood. Dialysis is often done with this system that uses an albumin-permeated membrane and charcoal absorber.

The patient is attached to the system by a catheter placed in either the subclavian, femoral, or external jugular vein.

• Blood passes through the albumin membrane and charcoal adsorber.
• Blood is then returned to the patient’s body after the dialysis.

Complications

There is a risk of complications when using any of the extracorporeal liver support devices. The most common complication is bleeding due to the necessary use of anticoagulants.

Liver transplant

For many patients with acute liver failure, a liver transplant is recommended. However, this is not easily available, and outcomes are worse in severely ill patients and older patients. In reality, fewer than 10% of liver failure patients receive a transplant. Liver transplant survival is about 79% at 1 year and 72% at 5 years.

Procedure:

A liver transplant, being a complex procedure, might take up to 8 hours to complete.The following steps are done:

• The patient will be placed under general anesthetic, and a large cut will be made from the belly to the chest.
• The old liver is removed, and the new liver is placed into the abdomen.
• Blood vessels and bile ducts are connected so that the new liver can function.

Post-operative care:

After surgery, the patient is taken to the intensive care unit. They will be on a ventilator and have drainage tubes in place. They may also have a tube providing nutrition. Patients will be taken to a general ward after about two days and then discharged from the hospital after 14 days.

Complications:

There are possible complications of the surgery. These are listed below:

• Blood clots or bleeding
• Infection – often of the chest or urinary system
• Bile duct problems
• Rejection of the new liver

Patients who do not qualify for a liver transplant:

Patients who do not qualify for a liver transplant include those who have the following:

• Ventricular dysfunction: The ventricles are the large lower chambers of the heart that pump blood. Problems with these can make surgery too risky.
• Coronary artery disease: Severe coronary artery disease can also make transplantation risky.
• Cardiomyopathy: A severely enlarged heart can make surgery risky.
• Aortic stenosis: This affects  blood circulation because the aortic valve is too narrow.
• Severe heart valve disease: Like other severe cardiac conditions, this can make surgery risky.

References:

• Acharya, Subrat K. "Management in acute liver failure." Journal of clinical and experimental hepatology 5 (2015): S104-S115.
• Bernal, W., Auzinger, G., Dhawan, A., & Wendon, J. (2010). Acute liver failure. The Lancet, 376(9736), 190-201.
• Stutchfield, B. M., Simpson, K., & Wigmore, S. J. (2011). Systematic review and meta-analysis of survival following extracorporeal liver support. Journal of British Surgery, 98(5), 623-631.
• Tritto, G., Davies, N. A., & Jalan, R. (2012, February). Liver replacement therapy. In Seminars in respiratory and critical care medicine (Vol. 33, No. 01, pp. 70-79). Thieme Medical Publishers.
• Yarrarapu, S. N. S., & Sanghavi, D. (2021). Molecular absorbent recirculating system. StatPearls [Internet].

Disclaimer: Please note that Mya Care does not provide medical advice, diagnosis, or treatment. The information provided is not intended to replace the care or advice of a qualified health care professional. The views expressed are personal views of the author and do not necessarily reflect the opinion of Mya Care. Always consult your doctor for all diagnoses, treatments, and cures for any diseases or conditions, as well as before changing your health care regimen. Do not reproduce, copy, reformat, publish, distribute, upload, post, transmit, transfer in any manner or sell any of the materials on this page without the prior written permission from myacare.com.