Liver failure occurs when large parts of the liver become damaged and can't be repaired. The liver is unable to work properly. Liver failure can make you feel very unwell. Acute liver failure is life-threatening and needs emergency medical care. Liver failure often develops slowly over many years. This is called chronic liver disease. See separate leaflet called Cirrhosis for further information.
Liver failure can also develop rapidly over just a few days (acute liver failure). There are many causes of acute liver failure. These include paracetamol poisoning, infections (for example, hepatitis B or hepatitis C), acute fatty liver of pregnancy and a number of rare genetic conditions. For some people with liver failure the cause is not known.
What are the functions of the liver?
The liver has a number of essential functions for the body. These include:
- Removing toxic substances from the body, including alcohol.
- Helping to make sure the blood clots properly.
- Storage of substances - for example, iron and glycogen (which is used to store glucose - for energy).
- Helping your body to fight against infection.
- Releasing bile, which passes into the gut (bowel) to help break down (digest) fats.
How common is liver failure?
Acute liver failure is very uncommon:
- In the UK, there were 775 liver transplants performed in the year April 2012 to April 2013. The number of transplants has been increasing in recent years.
- In Scotland, acute liver failure affected about 6 in 1 million people between 1992 and 2009. The most common cause was an overdose of paracetamol.
Causes of liver failure
Liver failure is caused by damage to the cells in the liver. There are many possible causes of acute liver failure. Often no cause is found but the most common causes are:
- Paracetamol overdose. Taking too much paracetamol is a relatively common cause of acute liver failure. An overdose can occur either by taking one large quantity of paracetamol or by taking higher than recommended doses over a few days or longer.
- Medicines. Some prescription medicines can cause acute liver failure but this is very rare. Examples of medicines that can rarely cause acute liver failure include some antibiotics, non-steroidal anti-inflammatory drugs (NSAIDS) and some medicines used for epilepsy (anticonvulsants).
- Herbal supplements. Some herbal medicines and supplements have been linked to causing liver failure.
- Illegal drugs. Drugs such as ecstasy and cocaine may occasionally cause liver failure.
- Infections. Viral hepatitis infections (for example, hepatitis B or hepatitis C) may cause liver failure. Other viruses that can cause acute liver failure include Epstein-Barr virus, cytomegalovirus and herpes simplex virus.
- Liver cancer. Cancer that either starts in the liver or has spread to the liver from other parts of the body may cause liver failure.
- Poisons (toxins). Toxins that can cause acute liver failure include some poisonous mushrooms.
- Autoimmune hepatitis. This is a disease in which your body's defence system (immune system) attacks your liver, causing inflammation and damaging the liver cells.
- Diseases of the veins in the liver. Some diseases (for example, Budd-Chiari syndrome) can cause blockages in the veins of the liver, which can lead to acute liver failure.
- Metabolic diseases. Some rare metabolic diseases may cause acute liver failure. These include haemochromatosis, alpha-1 antitrypsin deficiency, Wilson's disease, fructose intolerance, galactosaemia and tyrosinaemia.
- Reye's syndrome. This is a rare condition that mainly affects children and young adults. It can cause brain injury as well as liver failure. The cause is not known.
Acute liver failure can occur in a person who already has chronic liver disease when the liver function suddenly becomes much worse. This is called acute-on-chronic liver failure. The three most common causes of chronic liver disease in the UK are obesity, hepatitis infection and alcohol abuse. A number of chronic liver diseases gradually lead to liver cirrhosis. There is often no identified cause for the liver function suddenly becoming worse. However, known triggers include an infection or drinking alcohol. See separate leaflet called Cirrhosis for more information about chronic liver disease and cirrhosis.
Liver failure symptoms
In the early stages chronic liver disease may not cause any symptoms. There may be vague symptoms such as:
- Feeling sick (nausea).
- Loss of appetite.
- Feeling tired.
More advanced chronic liver disease or acute liver failure may cause serious symptoms. These may include:
- Your skin and the whites of your eyes may become yellow (jaundice).
- Your tummy (abdomen) may become swollen because of a build-up of fluid (ascites). Your liver and spleen may also be enlarged.
- Bleeding easily and bruising without any injury.
- Your body may become very dry (dehydrated).
- The palms of your hands may become red (called liver palms).
- You may develop a slow abnormal movement of your wrist (called a liver flap).
Liver failure can also cause other symptoms due to the complications of liver failure. These include:
- Bleeding from the bowel, which may cause you to bring up (vomit) blood (haematemesis) or your stools to become very dark or black (this is caused by digested blood passing through your bowel and into your stools - it is called melaena).
- Acute liver failure, which can badly affect how our brain works and may cause you to feel drowsy and confused, and to have problems with memory and concentration, as well as having hallucinations.
- Acute liver failure, which may even cause you to go into a coma. Severe difficulty with brain functions caused by liver failure is called hepatic encephalopathy.
How is liver failure diagnosed?
- The first tests are blood tests (including liver function tests) to see how your liver is working. Blood tests will also be used to check for possible underlying causes of liver failure, such as viral hepatitis.
- Scans are arranged to look at the structure of your liver and to check for other possible causes of liver failure. These scans may include an ultrasound scan, a computerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan.
- Some people with liver failure will need to have a liver biopsy to help find out the cause of the liver failure.
Liver failure treatment
The cause of the liver failure may need specific treatment. It is essential to avoid drinking any alcohol, even if alcohol abuse isn't the cause of the liver failure. Any medicine that has caused liver failure will need to be stopped immediately.
Medicines are used to reduce the effects of liver failure on your body. These include medicines to reduce stomach acid (for example, a proton pump inhibitor). Often help with food intake is needed using a tube passed through the nose into the stomach (nasogastric tube) or a tube placed through the skin directly into the stomach (PEG feeding tube).
Other treatments may be needed to treat any complications of liver failure such as excess fluid in your brain (cerebral oedema), reduced ability of your blood to clot, brain dysfunction (hepatic encephalopathy) or acute kidney injury.
A liver transplant may be life-saving if a suitable donor liver graft becomes available. Various artificial liver devices have been developed and they may bridge the gap until a liver is available for transplant or until the liver failure recovery.
What are the complications of liver failure?
Liver failure may cause various complications, which are often very serious and need urgent medical attention. The complications of liver failure include:
- Reduced protection against infection.
- Fluid build-up in your brain (cerebral oedema).
- Oesophageal varices. These are dilated veins in the gullet (oesophagus) leading down into the stomach. They may cause massive bleeding and this can be life-threatening.
- Bleeding (haemorrhage) from other parts the gut (bowel).
- Acute kidney injury.
- Severe breathing problems (respiratory failure).
What is the outlook?
- The outlook (prognosis) depends on the cause of the hepatic failure, the severity of the symptoms and any complications.
- The outlook for acute liver failure has greatly improved. In the past most people with acute liver failure died but many now survive as a result of improvements in intensive medical care.
Further reading and references
EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure; European Association for the Study of the Liver (2017)
Bernal W, Wendon J; Acute liver failure. N Engl J Med. 2013 Dec 26369(26):2525-34. doi: 10.1056/NEJMra1208937.
Hernaez R, Sola E, Moreau R, et al; Acute-on-chronic liver failure: an update. Gut. 2017 Mar66(3):541-553. doi: 10.1136/gutjnl-2016-312670. Epub 2017 Jan 4.
Bernal W, Lee WM, Wendon J, et al; Acute liver failure: A curable disease by 2024? J Hepatol. 2015 Apr62(1 Suppl):S112-20. doi: 10.1016/j.jhep.2014.12.016.