Overview
The syndrome of severe liver injury caused by various reasons, resulting in the decline of liver physiological functions.
Viral hepatitis, alcoholism, drugs, autoimmune liver disease and other factors can be induced.
Weakness, yellowing of skin and sclera, vomiting of blood, ascites, oliguria and personality changes.
Including dietary modification, drug treatment, etc. In advanced stage, artificial liver or liver transplantation can be carried out.
What is Liver Failure?
Definition
Liver failure is a group of clinical syndromes characterized by severe liver damage caused by various factors, resulting in severe impairment or loss of compensation of synthesis, detoxification, metabolism and biotransformation functions, with jaundice, coagulation dysfunction, hepatorenal syndrome, hepatic encephalopathy, ascites and other major manifestations.
Classification
According to the history, onset characteristics and the rate of progression of the disease, it is classified into 4 types:
Acute liver failure
Acute onset of liver failure without history of underlying liver disease, characterized by hepatic encephalopathy of II degree or higher within 2 weeks.
Subacute liver failure
More acute onset, no history of underlying liver disease, clinical manifestations of liver failure in 2 weeks to 6 months.
Slow plus acute liver failure
On the basis of chronic liver disease, as well as certain triggers, the clinical manifestations of acute hepatic decompensation and liver failure suddenly appear.
Common triggers include bleeding, alcohol and drugs. It is the main type of liver failure in China.
Chronic liver failure
On the basis of cirrhosis, chronic liver failure is characterized by recurrent ascites and/or hepatic encephalopathy due to the slow onset of progressive decompensation of liver function.
It is characterized by a longer course of the disease and has a better prognosis than other types of liver failure.
Morbidity
There is a lack of authoritative or generally recognized statistics on the incidence of liver failure in China.
Slow plus acute liver failure is the main type of liver failure in China.
The most common cause in China is hepatitis B virus infection.
Questions you may be concerned about
Can liver failure be cured?
Some acute liver failure can be cured, but most liver failure has a poor prognosis.
The prognosis of liver failure is mainly related to the severity and cause of the disease. Early intervention in acute liver failure has the possibility of cure; if liver failure is advanced, the necrosis of liver cells exceeds the regenerative and repair capacity of liver cells, the prognosis is poor, and it is difficult to recover with treatments other than liver transplantation.
How long can a patient with liver failure live?
How long a liver failure patient can live depends on the patient’s condition. If the patient receives regular treatment, and the patient is in good physical condition, recovers quickly, and is treated with artificial liver or liver cell transplantation in time, the success rate of rescue is higher, and the survival period will be longer at this time, and even long-term survival is possible.
Liver failure patients who do not receive regular treatment, the survival period is shorter, and even at any time life-threatening, depending on individual circumstances.
How is liver failure caused?
The main cause of liver failure in China is hepatitis virus (especially hepatitis B virus), followed by drugs and hepatotoxic substances (such as alcohol, chemicals, etc.); liver failure in children can also be seen in genetic metabolic diseases.
When the liver is subjected to severe liver damage caused by various factors, such as viruses, alcohol, drugs, etc., it results in massive necrosis of liver cells, leading to severe impairment or loss of hepatic function, which in turn leads to the emergence of clinical symptoms, such as disorders of coagulation mechanism, hepatic encephalopathy, ascites, and so on.
Causes
Causes
The main causes of liver failure include viral hepatitis, long-term alcohol consumption, acute fatty liver in pregnancy, poisons or drugs causing liver damage, parasitic infections such as schistosomiasis, metabolic liver disease and autoimmune liver disease.
Viral hepatitis
Viral hepatitis B, C and D may cause liver failure if uncontrolled and prolonged to chronic.
Cytomegalovirus, enterovirus, etc. can also cause liver failure.
Long-term alcohol consumption
Long-term alcohol abuse, alcohol will cause liver cell damage, the liver in the process of continuous damage repair, cirrhosis will occur, and eventually induce liver failure.
Acute Fatty Liver in Pregnancy
Acute fatty liver in pregnancy is a dangerous disease with rapid onset and rapid progression, and liver failure can occur.
Poisons or drugs
Prolonged or repeated exposure to hepatotoxic chemicals such as arsenic-containing pesticides and carbon tetrachloride, or long-term use of hepatotoxic drugs such as isoniazid, octocrylene, and methotrexate can also lead to liver failure.
Metabolic diseases
Metabolic disorders such as hemochromatosis and hepatomegaly (Wilson’s disease) can also cause cirrhosis, which can lead to liver failure.
Autoimmune diseases
Diseases such as primary biliary cholangitis, primary biliary cirrhosis, and primary sclerosing cholangitis can cause liver failure.
Pathogenesis
Hepatic necrosis is the basic mechanism leading to liver failure.
Hepatitis viruses can attack hepatocytes and cause chronic inflammation.
Chronic inflammation can lead to the appearance of cytokines such as tumor necrosis factor, interleukins, and transforming growth factor beta 1.
Cytokines can mediate abnormal immune responses, such as immune damage, which can secrete toxins on hepatocytes and cause associated damage; they can also form a chain reaction that amplifies hepatocyte damage.
Symptoms
Typical symptoms
Systemic symptoms
Fever, usually persistent low-grade fever.
Weakness and malaise.
Extreme wasting occurs due to metabolic abnormalities.
Digestive tract symptoms
Loss of appetite, especially aversion to grease, etc.
Nausea and vomiting.
Bloating and abdominal pain.
Skin symptoms
Yellowish staining of the skin and sclera (jaundice) all over the body and darkening of the facial skin.
Liver palms: reddening of the skin on the palms of the hands at the level of the major and minor fissures, which fades when pressed.
Spider nevus: red pinpoint-like with tortuous blood vessels extending radially in all directions, resembling a spider. Pressing on the small artery in the center can fade the color.
Bleeding symptoms
Bleeding gums, especially when brushing teeth.
Nasal bleeding, which may occur in the absence of trauma.
Skin petechiae and ecchymosis.
Symptoms of endocrine disorders
Women experience menstrual disorders, infertility, and even amenorrhea.
Males may present with breast development, etc.
Symptoms of portal hypertension
Vomiting blood.
Black stool or blood in stool.
Fluid buildup in the abdominal cavity (ascites).
Pain in the right upper abdomen (liver area).
Varicose veins in the abdominal wall.
Accompanying Symptoms
Liver failure may be accompanied by electrolyte disturbances such as hyponatremia. Nausea, vomiting, malaise, dizziness, decreased muscle tone, and decreased tendon reflexes may be seen.
Complications
Hepatic encephalopathy: impaired consciousness, behavioral disorders and coma are seen, even inability to deal with one’s daily life.
Hepatorenal syndrome: oliguria, anuria and decreased blood pressure occur, and even coma may occur.
Hepatopulmonary Syndrome: Difficulty in breathing, bruising of the lips and nails, pestle-like fingers (toes), and supine breathing.
Metabolic abnormalities: hypoglycemia, severe hypoglycemia can occur due to impaired metabolism of glucose by the liver.
Secondary infections: Symptoms vary depending on the infectious disease, mainly manifesting as fever, etc.
Consultation
Department of Medicine
Gastroenterology
It is recommended to consult a doctor when abnormal liver function, coagulation dysfunction, or unexplained symptoms such as loss of appetite, fatigue, lethargy, abdominal distension, dark complexion, or jaundice are detected during physical examination.
Emergency Department
When symptoms such as vomiting blood, blood in stool, or impaired consciousness occur, immediate medical attention is recommended.
Preparation for medical treatment
Information on how to get to the doctor: registration, preparation of documents, and common problems.
Tips for seeking medical treatment
Before seeking medical treatment, try to record the symptoms you have experienced, their duration, etc. for the doctor’s reference.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Where is the discomfort? How long has the discomfort lasted?
How has your appetite been recently?
Has there been any recent change in weight?
Is there any itching of the skin?
Has there been a persistent low-grade fever?
Has there been any blood in vomit or stool?
Have you had any tests and what were the results?
Have you taken any medications recently?
List of medical history
Any previous diseases of the hepatobiliary system, such as hepatitis B?
What is the occupation?
Do you drink alcohol? How long have you been drinking alcohol? What is the daily amount of alcohol consumed?
Any recent blood transfusions or use of blood products?
Any allergies to foods, medications?
Checklist
Test results for the last six months, which can be brought to the doctor’s office
Blood test, urine test, stool test
Liver Function
Virology test
Coagulation Function Tests
Autoantibody test
Abdominal Ultrasound, Abdominal CT, Abdominal MRI
Electroencephalogram
Medication List
Medications used in the last 3 months, if available in boxes or packages, bring them with you to the doctor’s office
Hepatoprotective drugs: Liver Tablets, Silymarin
Antibacterial drugs: cefuroxime, amoxicillin, vancomycin
Anti-tuberculosis drugs: Isoniazid, Rifampicin
Immunosuppressants: methotrexate
Diagnosis
Disease diagnosis
The diagnosis of liver failure should be based on a combination of relevant history, characteristic clinical manifestations, and laboratory, EEG, imaging, and pathologic findings.
Medical history
History of viral hepatitis, chronic alcohol consumption, and fatty liver.
Clinical manifestations
Symptoms: These include systemic symptoms such as fatigue and lethargy, digestive symptoms such as bloating and loss of appetite, and bleeding from the gums and nose.
Signs and symptoms: The doctor will check whether there is yellowing of the skin and sclera, the appearance of liver disease, and fluid accumulation in the abdominal cavity, etc. The doctor will also check whether there are characteristic signs of complications such as fluttering tremor, which is crucial to the diagnosis.
Laboratory tests
Liver function tests
Liver function tests such as serum bilirubin, serum albumin, serum aminotransferases, and blood ammonia can help diagnose liver failure.
In the early stages of the disease, there may be significant elevation of the enzyme glutamic oxaloacetic aminotransferase (GAT) and glutamic procyanic aminotransferase (GPA), but as the disease progresses, there may be a decrease in the enzyme due to massive necrosis of liver cells.
Total bilirubin is elevated, with a predominance of direct bilirubin, which is separated from the decrease in aminotransferases by the so-called “bilirubin separation”.
A decrease in the ratio of branched-chain amino acids to aromatic amino acids may assist in the diagnosis of complications of liver failure (hepatic encephalopathy).
A decrease in prealbumin concentration is important in the early diagnosis of liver failure.
Etiologic tests
Etiologic tests help to diagnose the etiology of liver failure and guide the subsequent treatment plan.
Pathogenetic examination
Hepatitis B five indexes test, Hepatitis B virus (HBV-DNA) test.
Hepatitis C virus (HCV-RNA) test and genotyping.
Serum copper and copper blue protein test, serum iron test.
Autoantibody test.
Coagulation Function Test
The prothrombin time can be prolonged in liver failure, and the prothrombin activity can be significantly decreased, usually less than 40%; in addition, the International Normalized Ratio (INR) can be above 1.5.
Coagulation function tests can help doctors determine the prognosis.
Imaging examination
Imaging tests for liver failure are mainly ultrasound or CT or magnetic resonance imaging.
Imaging tests can find out if there is an accumulation of fluid in the abdominal cavity, and can also observe the morphological changes of the liver.
Electroencephalography
An EEG is a test that determines whether the brain is functioning normally by measuring the electrical signals released during brain activity.
The use of EEG is aimed at the diagnosis of hepatic encephalopathy, and characteristic EEG waveforms such as triphasic waves may be present.
Differential Diagnosis
Liver failure is not a diagnosis of a separate disease, but rather a determination of the degree of liver function impairment, and therefore does not require a differential diagnosis from other diseases.
Treatment
Treatment of liver failure includes general supportive therapy, drug therapy, artificial liver therapy, and liver transplantation.
General supportive treatment
Diet
Supply energy at 35-40 kcal/kg body weight per day.
If adequate nitrogen intake cannot be obtained orally, consider taking branched-chain amino acid supplements under medical supervision.
In case of steatorrhea, apply a low-fat diet. Patients may also apply a medium-chain triglyceride diet under medical supervision.
Carbohydrates should be consumed 300 to 450 grams per day to ensure glycogen reserves.
Eat fewer and more frequent meals, and those who can eat by mouth can have 4 to 6 meals per day (including additional meals before bedtime).
Use less or no spicy and stimulating food, and focus on a light diet (less salt, less sugar, less oil).
Patients who have developed esophageal varices need to avoid hard, coarse and dry foods, such as coarse grains, cookies, ham, nuts, vegetables and fruits high in fiber; vegetables and fruits can be chopped and juiced for drinking, and nuts and nuts can be crushed and added to cooked dishes for consumption.
Those with abdominal fluid should limit sodium intake (no more than 2 grams of sodium per day) and take care to supplement protein.
Supportive therapy
Correct electrolyte as well as acid-base balance disorders.
Replenish adequate circulating blood volume by fluid or blood transfusion.
Control infection, requiring isolation if necessary.
Avoid hepatotoxic drugs.
Lifestyle
Avoid staying up late and ensure sleep.
Try to rest in bed and refrain from physical labor and exercise.
Medication
Glucagon – insulin: it has the effect of reducing hepatocyte necrosis and promoting hepatocyte regeneration; it can also play the role of adjusting amino acid metabolism.
Human blood albumin: intravenous infusion of albumin can increase colloid osmotic pressure and reduce cerebral edema and peritoneal effusion.
Probiotics: Probiotics can promote the growth of probiotics and inhibit the reproduction of harmful bacteria to achieve the purpose of adjusting the balance of intestinal microbial environment, which can help to improve hepatic encephalopathy caused by liver failure.
N-acetylcysteine: It can be used to treat liver failure caused by acetaminophen and muscarinic poisoning.
Hepatocyte growth stimulating hormone: this drug can accelerate the repair of liver tissue, thus accelerating the improvement of liver function and regaining physiological function.
Artificial liver and liver transplantation
When drug treatment is ineffective or ineffective, artificial liver or liver transplantation can be considered.
Artificial Liver Treatment
Artificial liver is a device that is artificially created outside of the body to remove harmful substances produced by metabolism and replenish bile and other biologically active substances produced by the liver, in order to achieve the therapeutic purpose of replacing the diseased liver to fulfill its functions.
There are three types of artificial livers: non-biological, biological and combined, and the non-biological type is more commonly used today.
Liver transplantation
Liver transplantation is the most effective treatment for liver failure. According to the statistics, the survival rate of acute liver failure without liver transplantation is only 10-30%, while the survival rate can be increased to 80-90% after liver transplantation.
Indications
Liver transplantation is indicated when the liver function reserve is insufficient and drug therapy is ineffective.
Contraindications
Surgical contraindications to liver transplantation are categorized into absolute and relative contraindications.
Absolute contraindications to liver transplantation:
Difficult to control systemic infection.
Extrahepatic malignant tumors that are difficult to eradicate.
Alcoholism or drug addiction that is difficult to quit.
Combined serious organic lesions of heart, brain, lungs and other important organs.
Difficult to control mental illness.
Relative contraindications to liver transplantation are:
Age over 65 years old.
Malignant tumors of the liver with thrombosis or metastasis in the main portal vein.
Comorbidities such as diabetes mellitus, cardiomyopathy, and other diseases with poor prognosis.
Severe infections such as sepsis due to biliary tract infection.
Patients with AIDS or human immunodeficiency virus infection.
Anatomical abnormalities such as obvious portal vein thrombosis.
Prognosis
Cure
Some drug-induced liver injuries can be cured after discontinuing the drugs in question and with aggressive treatment.
Drug treatment can relieve symptoms and slow down the progress of the disease, but it is difficult to cure liver failure for some patients; liver transplantation is to use a more intact liver for transplantation, which can reverse liver failure from the root, and it is one of the most important methods to cure liver failure at present.
The key to improving prognosis is early detection and treatment, focusing on controlling the progression of the primary disease, avoiding irrational use of medication, and providing reasonable life interventions and nutritional support.
Harmful
Affecting life: Liver failure will cause weakness, powerlessness, abdominal pain, abdominal distension, nausea and other symptoms, which will affect normal life.
Causes complications: such as hepatic encephalopathy, hepatorenal syndrome and portal hypertension. In severe cases, it may also be life-threatening.
Daily routine
Liver failure in daily life should pay attention to dietary regulation, life regulation, psychological regulation and many other aspects.
Daily life
Dietary regulation
Diet should be light, soft, easy to digest, non-stimulating, small and frequent meals, and should be chewed and swallowed slowly.
When cooking, the processing should be fine, avoid hard and rough food, such as fried food, hard fruit food; if there is upper gastrointestinal bleeding, strictly prohibit the consumption of the above food.
Staple food should be chosen softer, rice and noodles should be softer than normal. You can choose buns, steamed buns, wontons, dumplings (pay attention to the filling to choose less fiber) and so on.
Recommended high-quality protein diet: such as soybeans and their products (e.g. tofu, tofu brain, soy milk); milk and dairy products; various kinds of lean meat. However, you need to consult your doctor and dietitian for the amount to be consumed.
Consume more vegetables and fruits with lower fiber content to replenish vitamins and minerals, such as winter squash, pumpkin, cauliflower, apples, oranges, etc. It is advisable to chop, juice as well as make puree.
Life Adjustment
Rest in bed more often and do not engage in work with high energy consumption.
Try not to go out of town or go on long trips.
Psychological adjustment
Keep a positive attitude.
Family members should give comfort and psychological guidance to the patient, as well as patient company and good care.
Medication precautions
Any medication should be used under the guidance of a doctor.
Do not use drugs that may harm the liver or health supplements.
Non-steroidal anti-inflammatory drugs (e.g. ibuprofen, acetaminophen, indomethacin, etc.) may increase the risk of bleeding from ruptured esophageal varices and should be taken with caution.
Seek medical attention
Follow your doctor’s instructions for regular follow-up.
If symptoms do not resolve or worsen during treatment, or if new symptoms appear, it is necessary to go to the hospital.
Prevention
The prevention of liver failure is mainly from the prevention of causes, early detection and treatment, and adjustment of lifestyle and dietary habits.
Actively treat viral hepatitis, alcoholic liver disease, fatty liver and chronic heart failure.
Newborns and high-risk groups should be vaccinated against hepatitis B for prevention.
Chronic viral hepatitis requires active antiviral treatment as prescribed by the doctor.
Strict sterilization routines for instruments and strict selection of blood donors.
Abstain from smoking and drinking, especially avoiding large amount of alcohol intake.
Reasonable weight control, diversification of food types, dietary exercise phase balance, prevent the occurrence of non-alcoholic fatty liver.
Workers with long-term exposure to arsenic, carbon tetrachloride and other substances with hepatotoxicity need to pay attention to environmental pollution in the workplace, and certain occupational protection is recommended.
Adequate intake of nutrition is conducive to liver cell regeneration.
Maintain a pleasant mood, open-mindedness and less anger.
Cultivate some hobbies and interests outside of study and work.