Liver & intrahepatic bile ducts


Hepatic failure

Last author update: 1 March 2018
Last staff update: 21 April 2023 (update in progress)

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PubMed Search: Hepatic failure liver

Anthony W.H. Chan, M.B.Ch.B.
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Cite this page: Chan A. Hepatic failure. website. Accessed September 28th, 2023.
Definition / general
  • Characterized by acute and severe hepatic abnormalities with a high short term mortality (Gut 2017;66:541)
  • May occur with or without preexisting chronic liver disease
  • Various clinical definitions exist:
    • Acute hepatic failure
      • North America (AASLD): coagulopathy (INR ≥ 1.5) and hepatic encephalopathy without preexisting cirrhosis and with an illness of < 26 weeks duration
      • Europe (EASL): liver damage (elevated serum transaminases) and impaired liver function (jaundice and INR > 1.5) with an onset of encephalopathy within 24 weeks in absence of chronic liver disease (J Hepatol 2017;66:1047)
    • Acute on chronic hepatic failure
      • Europe (EASL CLIF): acute liver decompensation (ascites, encephalopathy, gastrointestinal bleeding or bacterial infection) in preexisting chronic liver disease defined by the chronic liver failure sequential organ failure assessment [CLIF-SOFA] score and 28 day mortality > 15% (Gastroenterology 2013;144:1426)
      • Asia Pacific (APASL): jaundice (serum bilirubin level of ≥ 5 mg/dL) and coagulopathy (INR ≥ 1.5 or prothrombin activity of > 40%), which are complicated within 4 weeks by clinical ascites or encephalopathy in patients with previously diagnosed or undiagnosed chronic liver disease (including cirrhosis) (Gut 2017;66:541)
  • Acute hepatic failure may also refer to fulminant hepatic failure, fulminant hepatitis or massive hepatic necrosis
  • Acute hepatic failure: 2,000 cases per year in the U.S.
  • Acute on chronic hepatic failure: 24% - 40% of hospitalized patients with cirrhosis (Gut 2017;66:541)
Clinical features
  • Jaundice
  • Coagulopathy
  • Hepatic encephalopathy
  • In patients with acute on chronic hepatic failure, clinical features of cirrhosis may also be present
Fuliminant hepatic failure
  • Uncommon (< 1%) complication of acute viral hepatitis
  • Progresses from onset of symptoms to hepatic encephalopathy in 2 - 3 weeks in previously healthy patient
  • Orderly regeneration due to massive destruction of confluent lobules
  • Liver can regenerate after massive necrosis if connective tissue framework is intact
  • Regeneration: portal ductules increase in size and number and become dilated
  • Individual hepatocytes with clear cytoplasm appear from ductules
  • Ductules are transformed into hepatocytes and form round cell clusters, which organize into trabeculae with fibrosis
  • Lobular architecture is established
  • May become normal at 14 months (Mod Pathol 2000;13:152)
  • Causes: viruses (hepatitis B, C), drugs (acetaminophen, carbon tetrachloride, halothane, isoniazid, rifampin), acute fatty liver of pregnancy, hepatic vein obstruction, hyperthermia, ischemia, tumor, Wilson disease
  • Subfulminant hepatitis: less rapid, up to 3 months to hepatic encephalopathy
Case reports
  • Liver transplant, auxiliary partial orthotopic liver transplant
  • Mortality without liver transplant is 25 - 90% (Semin Liver Dis 2008;28:175)
Gross images

Contributed by Anthony W.H. Chan, M.B.Ch.B.

Acute hepatic failure

Images hosted on other servers:

Explanted liver with large areas of hemorrhage and necrosis

Microscopic (histologic) description
  • Panacinar hepatic necrosis with collapse of reticulin framework
  • Variable inflammatory infiltrate, depending on etiology
  • Variable ductular reaction
  • Microscopic features of cirrhosis in patients with acute on chronic hepatic failure
Microscopic (histologic) images

Contributed by Anthony W.H. Chan, M.B.Ch.B.

Panacinar hemorrhagic necrosis

Prominent ductular reaction

Collapse of reticulin framework

Images hosted on other servers:

Post isoflurane anesthesia

Explanted liver
massive necrosis and
architectural collapse

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