The Clinical Spectrum and Manifestations of Acute and Acute on Chronic Liver Failure

Glass, Daniel M.; Al-Khafaji, Ali

Acute liver failure (ALF) is characterized by the onset of coagulopathy and encephalopathy caused by hepatocyte injury that evolve over days or weeks. The absence of existing liver disease distinguishes ALF from acute on chronic liver failure (ACLF). Acetaminophen toxicity, viral, autoimmune and ischemic hepatitis are some of the common causes of ALF. Clinical features include abdominal pain, nausea, vomiting and depressed mental status. However, these nonspecific symptoms can rapidly be followed by multiple organ failure and death. Deterioration often occurs despite supportive and therapeutic measures. Liver transplantation is the only definitive treatment in patients who do not recover their liver function. ACLF on the other hand involves acute deterioration in liver function in a patient with pre-existing chronic liver disease leading to different organ failures. There are different definitions, classifications, and prognostic assessments of patients with ACLF. Infections (bacterial or viral) and inflammation (acute alcoholic hepatitis) are common precipitating events, although, some patients develop ACLF without a clear trigger. Similar to ALF, clinical features include jaundice, abdominal pain, nausea, vomiting and depressed mental status which may quickly deteriorate to multiple organ failure and death. Clinical management focuses on supportive care and management of specific precipitating factors. Liver transplantation remains a definitive treatment in patients who do not improve despite medical support.