Liver & intrahepatic bile ducts
General
Hepatic failure
Author: Anthony W.H. Chan, M.B.Ch.B.
Last author update: 1 March 2018
Last staff update: 21 April 2023 (update in progress)
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PubMed Search: Hepatic failure liver
Table of Contents
Definition / general | Terminology | Epidemiology | Etiology | Clinical features | Fuliminant hepatic failure | Case reports | Treatment | Gross images | Microscopic (histologic) description | Microscopic (histologic) imagesCite this page: Chan A. Hepatic failure. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/liverhepaticfailure.html. 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
Terminology
- Acute hepatic failure may also refer to fulminant hepatic failure, fulminant hepatitis or massive hepatic necrosis
Epidemiology
- 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)
Etiology
- Acute hepatic failure (J Hepatol 2017;66:1047)
- Acetaminophen (up to 43%)
- Nonacetaminophen drug induced liver injury (up to 32%)
- Acute hepatotropic virus hepatitis (up to 68%)
- Others (up to 27%)
- Unknown (up to 27%)
- Acute on chronic hepatic failure (Gut 2017;66:541)
- Chronic viral hepatitis (12 - 81%)
- Alcoholic liver disease (7 - 75%)
- Others (3 - 22%)
- Unknown (4 - 20%)
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
- 15 year old boy with autoimmune hepatitis / primary sclerosing cholangitis overlapping syndrome who developed acute on chronic liver failure (Clin Exp Hepatol 2017;3:28)
- 42 year old woman with massive hepatic necrosis following ingestion of acetic acid (concentrated) (Arch Pathol Lab Med 2000;124:127)
- 51 year old woman with acute hepatic failure due to massive sinusoidal infiltration of liver by breast cancer cells (BMC Gastroenterol 2017;17:166)
- 60 year old man with acute hepatic failure due to pembrolizumab for metastatic liver cancer (Medicine (Baltimore) 2017;96:e9431)
- 60 year old woman with massive hepatic necrosis following exposure to phenytoin and trimethoprim / sulfamethoxasole (Arch Pathol Lab Med 2000;124:1800)
- 63 year old woman with subacute hepatic failure after administration of troglitazone (Hum Pathol 2000;31:250)
- 63 year old woman with acute on chronic hepatic failure due to sorafenib for hepatitis B related hepatocellular carcinoma (Mol Clin Oncol 2017;7:693)
- Two people from the same family with acute hepatic failure due to acute hepatitis A (Medicine (Baltimore) 2017;96:e7847)
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 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
demonstrating
massive necrosis and
architectural collapse
