Acute Liver Failure

Acute liver failure is a medical emergency with high mortality.
It can deteriorate rapidly and often requires early senior involvement and transfer to a specialist liver centre.

This guide focuses on recognising it early and knowing what to do on the ward and on-call.

What is acute liver failure?

Acute liver failure is:

Rapid loss of liver function (days to weeks) in a person without pre-existing cirrhosis, with evidence of:

  • Coagulopathy (INR ≥1.5)
  • Hepatic encephalopathy

The key idea:

A previously healthy liver suddenly fails.

This is very different from decompensated chronic cirrhosis.

How does it present?

Early features can be subtle.

Common presentations:

  • Jaundice
  • Nausea and vomiting
  • Right upper quadrant pain
  • Fatigue
  • Confusion
  • Drowsiness
  • Easy bruising or bleeding

Red flags suggesting severe disease:

  • Confusion or reduced GCS
  • Bleeding
  • Hypotension
  • Hypoglycaemia
  • Rising INR
  • Worsening acidosis

If encephalopathy develops, the patient is already critically unwell.

Common causes (think practically)

You don’t need every rare cause — focus on what you actually see.

Most common causes in the UK:

  • Paracetamol (acetaminophen) overdose
  • Viral hepatitis (especially Hep B, occasionally Hep A/E)
  • Drug-induced liver injury (e.g. antibiotics, anti-epileptics, herbal meds)
  • Alcohol-related acute hepatitis (severe cases)

Less common but important:

  • Autoimmune hepatitis
  • Ischaemic hepatitis (shock liver)
  • Budd–Chiari syndrome

On the ward, always ask

Could this be paracetamol toxicity?

Even if the patient:

  • Denies overdose
  • Is unsure about timing
  • Took “therapeutic” doses over several days

Paracetamol levels and history are critical.

First priority = recognise severity early

Look at:

  • Mental state (encephalopathy?)
  • INR trend
  • Bilirubin trend
  • Lactate
  • Glucose
  • Renal function
  • Observations / NEWS

ALF patients can look “not too bad” and then deteriorate within hours.

Immediate management on the ward (what juniors should actually do)

If you suspect acute liver failure:

Do immediately:

  • A–E assessment
  • Urgent senior review (medical registrar + consultant)
  • Bloods: FBC, U&E, LFTs, INR, glucose, lactate, VBG/ABG
  • Paracetamol level (always)
  • Hepatitis screen
  • Blood cultures if infection possible
  • Monitor glucose regularly (risk of hypoglycaemia)

Practical steps:

  • Start N-acetylcysteine (NAC) early if paracetamol possible (often given even if unsure)
  • Avoid sedatives
  • Careful fluid balance
  • Consider early antibiotics if infection suspected

Do not manage suspected ALF alone overnight.

When to escalate (this is key)

All suspected acute liver failure should be:

Discussed urgently with seniors and often with a specialist liver centre.

Escalate immediately if:

  • Encephalopathy present
  • INR rising
  • Hypoglycaemia
  • Acidosis
  • AKI
  • Lactate rising
  • Concern about deterioration

Many patients need:

  • HDU/ICU
  • Transfer to transplant centre
  • Multidisciplinary specialist input

Delay in escalation can cost the patient their transplant window.

Common mistakes juniors make

  • Assuming jaundice = chronic liver disease
  • Forgetting to check paracetamol level
  • Delaying NAC
  • Not monitoring glucose
  • Underestimating the significance of rising INR
  • Delaying senior escalation

Acute liver failure is rare — but when it occurs, speed matters.

Take-home concept

Acute liver failure is a time-critical diagnosis.
Your role is to recognise it early, start immediate supportive treatment, and escalate urgently to senior and specialist teams.