Liver and intrahepatic bile ducts - nontumor
General concepts
Hepatic failure


Topic Completed: 1 March 2018

Minor changes: 24 May 2020

Copyright: 2002-2020, PathologyOutlines.com, Inc.

PubMed Search: Hepatic failure[TI] liver Review[ptyp]


Anthony W.H. Chan, F.R.C.P.A.
Page views in 2019: 1,244
Page views in 2020 to date: 756
Cite this page: Chan A. Hepatic failure. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/liverhepaticfailure.html. Accessed May 30th, 2020.
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
    • 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)
Terminology
  • Acute hepatic failure may also refer to fulminant hepatic failure, fulminant hepatitis or massive hepatic necrosis
Epidemiology
Etiology
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
Treatment
  • Liver transplant, auxiliary partial orthotopic liver transplant
  • Mortality without liver transplant is 25 - 90% (Semin Liver Dis 2008;28:175)
Gross images

Contributed by W.H. Chan, FRCPA

Acute heptic 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 W.H. Chan, FRCPA

Panacinar hemorrhagic necrosis

Prominent ductular reaction

Collapse of reticulin framework



Images hosted on other servers:

Post isoflurane anesthesia

Explanted liver
demonstrating
massive necrosis and
architectural collapse

Back to top