The other term used for fulminant hepatic failure is acute liver failure. It is a sudden liver failure along with the development of hepatic encephalopathy. It is usually seen in people who never had any liver condition or might have stable liver conditions. Hepatic encephalopathy is a nervous system disorder in which the brain stops functioning as the liver does not remove toxins from the blood. Hepatic encephalopathy develops within eight weeks after the signs of jaundice are seen in the patient.
Based on the time interval between the development of jaundice and hepatic encephalopathy, fulminant hepatic failure is categorized as:
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Hyperacute Liver Failure: Within seven days.
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Acute Liver Failure: Between one to four weeks.
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Subacute Liver Failure: Between five to 12 weeks.
Fulminant hepatic failure is characterized by elevated liver enzymes in the blood, coagulopathy, which means the blood’s ability to coagulate is impaired, and encephalopathy. It is a life-threatening condition, but at times depending on the cause, it can be reversed with treatment.
What Are the Causes of Fulminant Hepatic Failure?
Liver failure happens when the cells of the liver are damaged and stop working. The probable causes of fulminant hepatic failure are:
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Overdose of Acetaminophen: In the United States of America and European countries, the most common cause of acute liver failure is an overdose of Acetaminophen. In other countries, this drug is known as Paracetamol. It is an over-the-counter drug. Taking one large dose of Acetaminophen or taking multiple doses above the recommended amount for several days can lead to sudden liver failure.
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Viral Hepatitis: The other main cause of acute liver failure is hepatitis. Hepatitis A, hepatitis B, and hepatitis E are mainly responsible for liver failure. Other viruses that can cause liver failure are the Epstein-Barr virus, Cytomegalovirus, and Herpes simplex virus.
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Prescription Medicines: Medicines like non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, anticonvulsants, and cancer medicines can lead to liver failure.
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Cancer: Any tumor developing in the liver or spreading to the liver can cause liver damage and hence liver failure.
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Herbal Supplements: Liver failure can be caused by herbal drugs and supplements like kava, skull cap, comfrey, ephedra (ma huang), and pennyroyal.
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Toxins: Toxins like carbon tetrachloride, which is an industrial chemical found in refrigerants and solvents and also in-home cleaning agents, can cause acute liver failure.
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Mushroom Poisoning: Mushrooms like Amanita phalloides, also known as death cap mushrooms, are not edible. It is a wild mushroom, it might seem safe to eat, but it is dangerous and causes liver failure.
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Diseases of the Veins of the Liver: Blockages in the veins of the liver can cause liver damage and, ultimately, liver failure. Vascular disease like Budd Chiari syndrome is one example.
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Autoimmune Disease: Autoimmune hepatitis, the condition in which the body’s own defense mechanism attacks the liver cells, can cause acute liver failure.
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Metabolic Diseases: Wilson’s disease and fatty liver in pregnancy may cause acute liver failure. Wilson’s disease is an inherited disorder that involves excess accumulation of copper in the organs.
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Heat Stroke: Excess physical exertion in a hot environment can also lead to acute liver failure.
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Shock: Any massive infection or shock can obstruct the blood supply to the liver and cause acute liver failure.
What Are the Symptoms of Fulminant Hepatic Failure?
The signs and symptoms of fulminant hepatic failure include:
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Yellowing of skin and sclera (jaundice).
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Pain in the belly in the upper right region.
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Tiredness.
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Nausea.
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Swelling in the abdomen.
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Sleepiness.
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Malaise (feeling unwell).
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Feeling disoriented or confused.
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Vomiting.
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Tremors.
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Musty breath.
How to Diagnose Fulminant Hepatic Failure?
A person who witnesses any of the above signs and symptoms should immediately seek a doctor’s advice as this is a life-threatening condition and to avoid worsening health conditions. The doctor would start with a medical history and physical examination. He may ask questions related to drug use, alcohol consumption, previous history of jaundice, a family history of liver disease, or any kind of exposure to toxins. During the physical examination, he would check for signs and symptoms and mental alertness of the patient.
Blood tests and urine tests are prescribed by the doctor. These include tests to check for autoimmune markers, arterial blood gas, acetaminophen levels, viral hepatitis serologies, and Human immunodeficiency virus (HIV) serology. If Wilson's disease is suspected, ceruloplasmin levels are checked. Tests are done to check for the time of blood clotting. The result of these tests indicates how well the liver is functioning. Fews scans of the liver are also prescribed by the doctor, which include an ultrasound of the abdomen, CT (computed tomography) scan, and MRI (magnetic resonance imaging) scan of the liver. This is done to check for any liver damage, blockages, tumors, or any other abnormalities.
A liver biopsy is also performed by taking a small tissue sample of the liver. It is examined thoroughly to find out the exact cause of liver failure and decide the effective treatment method.
What Are the Complications of Fulminant Hepatic Failure?
Fulminant hepatic failure can cause the following complications:
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Cerebral Edema: Cerebral edema is the accumulation of excess fluid in the brain. This fluid can lead to pressure build-up in the brain leading to seizures, disorientation, and confusion.
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Bleeding and Bleeding Disorders: Due to damage to the liver, the coagulation factors are present in a sufficient amount to clot the blood when there is bleeding. The upper gastrointestinal tract is the most common site of bleeding.
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Infections: People with fulminant hepatic failure are more prone to infections of the urinary tract, respiratory system, and blood.
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Renal Failure: In the case of an overdose of Acetaminophen, both liver and kidney failure are obvious.
What Are the Treatment Options for Fulminant Hepatic Failure?
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When the patient is taken to the hospital, he or she would be admitted to the ICU (intensive care unit), where the treatment would start depending on the cause of the liver failure. After the diagnosis is made, the medication will start.
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N-acetylcysteine (NAC) is given in case of an overdose of Acetaminophen. This is effective even in non-Acetaminophen liver failure. Antivirals are given for acute hepatitis B. Steroids are administered in case of autoimmune disorders. Penicillamine is given when the patient is diagnosed with Wilson's disease, and Penicillin is given in case of mushroom poisoning.
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One of the main aims of the treatment process is to prevent cerebral edema. It can be done by placing the head at an elevation, giving mannitol, hyperventilating, and taking cerebroprotective measures. Other complications of liver failure, if present, should also be treated accordingly.
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A liver transplant is indicated when medication and other treatment methods become ineffective. A liver transplant is a surgical procedure wherein the infected liver is replaced by a healthy liver donated by a donor.
How to Prevent Fulminant Hepatic Failure?
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Always take medications in the recommended dosage, especially Acetaminophen.
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Always avoid contact with other's blood or body fluids.
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Drink alcohol in moderation.
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Take vaccination for hepatitis A and hepatitis B.
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Do not consume wild mushrooms.
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Avoid getting in contact with any kind of toxins. Try wearing gloves in places where contact is unavoidable.
Conclusion
Fulminant liver failure is a complex syndrome with serious complications like excessive bleeding and increasing pressure in the brain and can be best managed when an early diagnosis is made. Moreover, taking good care of health and taking steps to prevent it is highly recommended as it is a deadly disease, with a mortality rate of 65 % to 85 %. The overall short-term survival rate with a liver transplant is more than 65 %.
