Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis - UpToDate 11/21/17, 8(52 PM Acute liver failure

11/21/17, 8(52 PM Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis - UpToDate 11/21/17, 8(52 PM

and <26 weeks). In patients with hyperacute or acute liver failure, cerebral edema is common, whereas it is rare
Official reprint from UpToDate in subacute liver failure [4]. On the other hand, renal failure and portal hypertension are more frequently
www.uptodate.com 2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved. observed in patients with subacute liver failure. These subcategories have been associated with prognosis, but
the associations reflect the underlying causes, which are the true determinants of prognosis. As an example,
patients with hyperacute liver failure tend to have a better prognosis than those with subacute liver failure. The
better prognosis is related to the fact that these patients often have acetaminophen toxicity or ischemic
hepatopathy, diagnoses associated with a better prognosis than many of the disorders that may result in
Acute liver failure in adults: Etiology, clinical manifestations, and diagnosis subacute liver failure, such as Wilson disease [2].

Authors: Eric Goldberg, MD, Sanjiv Chopra, MD, MACP ETIOLOGY Acute liver failure can result from a wide variety of causes, including (table 1 and table 2) [2,5]:
Section Editor: Robert S Brown, Jr, MD, MPH
Deputy Editor: Kristen M Robson, MD, MBA, FACG
Acetaminophen (paracetamol)
Idiosyncratic drug reactions
All topics are updated as new evidence becomes available and our peer review process is complete.
Viral hepatitis
Literature review current through: Oct 2017. | This topic last updated: Aug 12, 2015.
Alcoholic hepatitis (in which case it is considered to be acute-on-chronic liver failure) (see 'Definitions'
INTRODUCTION Acute liver failure is characterized by acute liver injury, hepatic encephalopathy, and an above)
elevated prothrombin time/international normalized ratio (INR). It has also been referred to as fulminant hepatic Autoimmune hepatitis
failure, acute hepatic necrosis, fulminant hepatic necrosis, and fulminant hepatitis. Untreated, the prognosis is Wilson disease
poor, so timely recognition and management of patients with acute liver failure is crucial [1]. Whenever possible, Ischemic hepatopathy
patients with acute liver failure should be managed in an intensive care unit at a facility capable of performing Budd-Chiari syndrome
liver transplantation.
Veno-occlusive disease
This topic will review the etiology, clinical manifestations, and diagnosis of acute liver failure in adults. The Acute fatty liver of pregnancy/HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome
prognosis and management of patients with acute liver failure is discussed separately. (See "Acute liver failure in Malignant infiltration (most often breast cancer, small cell lung cancer, lymphoma, melanoma, or myeloma)
adults: Management and prognosis".) Partial hepatectomy
Toxin exposure, including mushroom poisoning
The discussion that follows is consistent with the 2011 The American Association for the Study of Liver Diseases
Sepsis
guideline for the management of acute liver failure [2].
Heat stroke
DEFINITIONS Acute liver failure refers to the development of severe acute liver injury with encephalopathy Hemophagocytic lymphohistiocytosis (primarily a disorder of children) [6]
and impaired synthetic function (INR of 1.5) in a patient without cirrhosis or preexisting liver disease [2,3]. While
the time course that differentiates acute liver failure from chronic liver failure varies between reports, a commonly Viral and drug-induced hepatitis are the most common causes of acute liver failure in adults. In Australia,
used cutoff is an illness duration of <26 weeks. Denmark, the United Kingdom, and the United States, acetaminophen is the most common cause of acute liver
failure, whereas in Asia and some other parts of Europe, viral hepatitis predominates [7]:
Acute liver failure may also be diagnosed in patients with previously undiagnosed Wilson disease, vertically
acquired hepatitis B virus, or autoimmune hepatitis, in whom underlying cirrhosis may be present, provided the In the United States, the US Acute Liver Failure Study Group collected data on 1147 cases of acute liver
disease has been recognized for <26 weeks. On the other hand, patients with acute severe alcoholic hepatitis, failure from 23 sites between 1998 and 2007 [1]. The most common causes of acute liver failure were
even if recognized for <26 weeks, are considered to have acute-on-chronic liver failure since most have a long acetaminophen overdose (46 percent), indeterminate (14 percent), idiosyncratic drug reactions (12 percent),
history of heavy drinking. The approach to such patients is discussed elsewhere. (See "Clinical manifestations hepatitis B virus (7 percent), and hepatitis A virus (3 percent).
and diagnosis of alcoholic fatty liver disease and alcoholic cirrhosis" and "Prognosis and management of
Among 1014 patients with acute liver failure referred to King's College Hospital in the United Kingdom
alcoholic fatty liver disease and alcoholic cirrhosis".)
between 1973 and 1991, 57 percent were acetaminophen-induced, and 9 percent were attributable to
Acute liver failure can be subcategorized based upon how long the patient has been ill and various cutoffs have hepatitis B or D [8].
been used. We classify acute liver failure as hyperacute (<7 days), acute (7 to 21 days), or subacute (>21 days
Among 502 patients with acute liver failure referred to the Hospital Beaujon in France between 1972 and

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1990, 45 percent of the cases were related to hepatitis B or D, and 2 percent were attributable to has also been reported rarely in immunocompetent hosts. (See "Clinical manifestations and diagnosis of herpes
acetaminophen [8]. simplex virus type 1 infection", section on 'Hepatitis'.)

Among 856 patients with acute liver failure in Japan between 1998 and 2006, 51 percent of cases were due Immunocompromised patients, such as transplant recipients and HIV-infected individuals with advanced disease,
to viral hepatitis (42 percent hepatitis B), and 10 percent were due to drugs (including acetaminophen) [9]. are at increased risk for developing complicated herpes zoster infections including acute liver failure. Hepatic
involvement may occasionally develop in the absence of coincident rash. (See "Clinical manifestations of
Viral hepatitis Several viruses have been associated with acute liver failure, including hepatitis A, B, C, D, varicella-zoster virus infection: Herpes zoster", section on 'Complications in immunocompromised hosts'.)
and E. In addition, acute liver failure can be seen with herpes simplex virus, varicella zoster virus, Epstein-Barr
virus, adenovirus, and cytomegalovirus [1,7]. Epstein-Barr virus can affect virtually any organ system and has been associated with hepatitis and cholestasis.
While rare, fatal cases of hepatitis have been described. (See "Infectious mononucleosis in adults and
Acute liver failure is estimated to develop in 0.35 percent of patients with hepatitis A and in 0.1 to 0.5 percent of adolescents", section on 'Other'.)
patients with acute hepatitis B [10]. However, the incidence of acute liver failure from hepatitis B may be
underestimated. Precore or pre-S mutant hepatitis B viruses that are able to produce infection but do not The more common gastrointestinal manifestation of adenovirus is an acute diarrheal illness. However, hepatitis is
produce hepatitis B e antigen (precore mutants) or surface antigen (pre-S mutants) may be difficult to diagnose a well-described complication of adenovirus infection in immunocompromised hosts, especially with subgroup C
by routine serology. Thus, liver failure in such patients may be erroneously attributed to cryptogenic causes [11]. type 5. (See "Epidemiology and clinical manifestations of adenovirus infection", section on 'Gastrointestinal
This was illustrated in a study in which evidence of hepatitis B infection was detected by polymerase chain tract'.)
reaction (PCR) in 6 of 17 patients (35 percent) who underwent liver transplantation for what was initially thought
Liver function abnormalities are frequently encountered in patients with symptomatic cytomegalovirus infection.
to be non-A, non-B hepatitis [12]. (See "Hepatitis A virus infection in adults: An overview" and "Clinical
Subclinical transaminitis is the most common finding in immunocompetent patients, but occasionally, patients
manifestations and natural history of hepatitis B virus infection", section on 'Acute hepatitis' and "Clinical
present with more significant laboratory abnormalities or signs of hepatic dysfunction. (See "Epidemiology,
significance and molecular characteristics of common hepatitis B virus variants".)
clinical manifestations, and treatment of cytomegalovirus infection in immunocompetent adults", section on
In addition to acute hepatitis B, acute liver failure may also develop in patients who are receiving chemotherapy 'Hepatic manifestations'.)
or immunosuppression and have reactivation of previously inactive hepatitis B. (See "Hepatitis B virus
Acetaminophen and other hepatotoxins Acetaminophen is the most common toxin associated with acute
reactivation associated with immunosuppressive therapy".)
liver failure in the United States and other developed countries (table 2) [5]. The hepatotoxicity is dose-
Hepatitis C virus alone does not appear to be a significant cause of acute liver failure in the absence of dependent and rarely occurs at therapeutic doses (up to four grams per day in a patient without preexisting liver
coinfection with hepatitis B. In a study of 109 patients with acute hepatitis C, acute liver failure developed in 11 disease). (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and diagnosis"
(10 percent), 9 of whom had concurrent hepatitis B infection [13]. (See "Clinical manifestations and natural and "Acetaminophen (paracetamol) poisoning in adults: Treatment".)
history of chronic hepatitis C virus infection".)
Most cases occur after ingestion of large doses in an attempt to commit suicide. In addition, some patients
Infection with hepatitis D virus can lead to acute liver failure in patients with hepatitis B virus infection. A patient unknowingly take large amounts of acetaminophen when multiple acetaminophen-containing medications are
may either acquire both viruses at the same time (coinfection) or acquire hepatitis D in the setting of preexisting taken together or if acetaminophen-containing medications are not taken as directed (a "therapeutic
chronic hepatitis B (superinfection). The risk of acute liver failure appears to be higher among patients who are misadventure"). Acute liver failure can also result from normally therapeutic doses in patients who have
coinfected than in those with hepatitis D superinfection or with acute hepatitis B alone. (See "Pathogenesis, underlying liver disease (particularly with ongoing alcohol use, which induces the cytochrome P450 system) or
epidemiology, natural history, and clinical manifestations of hepatitis D virus infection".) who are taking medications known to induce the cytochrome P450 system (particularly CYP2E1), such as
anticonvulsants (figure 1).
Hepatitis E virus is a significant cause of liver failure in countries where it is endemic, such as Russia, Pakistan,
Mexico, and India. Overall, the case-fatality rate for hepatitis E is 0.5 to 3 percent. However, among women who Other toxins associated with acute liver failure include mushroom poisoning (most often Amanita phalloides) and
are pregnant, the mortality rate increases to 15 to 25 percent. (See "Hepatitis E virus infection", section on 'Acute carbon tetrachloride. (See "Amatoxin-containing mushroom poisoning (eg, Amanita phalloides): Clinical
hepatitis E'.) manifestations, diagnosis, and treatment" and "Hydrocarbon poisoning", section on 'Acute systemic toxicity'.)

Acute liver failure is a rare complication of HSV infection. Both HSV-1 and HSV-2 have been implicated as Idiosyncratic drug reactions Unlike acute liver failure due to acetaminophen, which is dose-related, acute
etiologic agents. Those at risk include neonates, patients taking steroids, HIV-infected patients, those with cancer liver failure due to idiosyncratic drug reactions (known as drug-induced liver injury [DILI]) is dose-independent.
or myelodysplastic syndromes, and pregnant women. HSV hepatitis has also been reported as an early cause of DILI usually occurs within six months of drug initiation [2]. Drugs commonly implicated in cases of DILI include
death after liver transplantation with concomitant lung and gastrointestinal involvement. HSV-related hepatitis antibiotics, nonsteroidal anti-inflammatory drugs, and anticonvulsants (table 2). Herbal medications and dietary

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supplements have also been associated with acute liver failure. (See "Drug-induced liver injury" and Cerebral edema may develop in patients with acute liver failure leading to increased intracranial pressure [5].
"Hepatotoxicity due to herbal medications and dietary supplements".) Cerebral edema is uncommon in patients with grade I or II encephalopathy, but it is present in 25 to 35 percent of
those with grade III encephalopathy and in approximately 75 percent of those with grade IV encephalopathy
Hypoperfusion Hypoperfusion of the liver can result in ischemic hepatitis and acute liver failure. [14,15]. Pupillary changes are one sign of increased intracranial pressure. The pupils may progress from having
Hypoperfusion may result from systemic hypotension due to causes such as cardiac dysfunction, sepsis, or a normal response (typical with grade I encephalopathy), to being hyperresponsive (grade II to III
drugs. Hypoperfusion of the liver may also be seen with Budd-Chiari syndrome (hepatic vein thrombosis), veno- encephalopathy), to being slowly responsive (grade III to IV encephalopathy). As the coma worsens, the pupils
occlusive disease, or the use of vasoconstricting drugs such as cocaine and methamphetamine. (See "Ischemic may become fixed and dilated (a sign typically associated with brainstem herniation).
hepatitis, hepatic infarction, and ischemic cholangiopathy" and "Budd-Chiari syndrome: Epidemiology, clinical
manifestations, and diagnosis" and "Diagnosis of hepatic sinusoidal obstruction syndrome (veno-occlusive Other clinical features of increased intracranial pressure include systemic hypertension, bradycardia, respiratory
disease) following hematopoietic cell transplantation".) depression (Cushing's triad), seizures, and paralysis of other brain stem reflexes (eg, oculocephalic reflex,
corneal reflex, jaw reflex, cough response to tracheobronchial suctioning). (See "Evaluation and management of
CLINICAL MANIFESTATIONS By definition, patients with acute liver failure have severe acute liver injury elevated intracranial pressure in adults", section on 'Clinical manifestations'.)
(demonstrated by liver test abnormalities) with signs of hepatic encephalopathy and a prolonged prothrombin
time (INR 1.5). Other clinical manifestations may include jaundice, hepatomegaly, and right upper quadrant Seizure activity in patients with acute liver failure is common, but may be difficult to detect if patients are
tenderness. intubated and receiving paralytics. In the control arm of one trial, 7 of 22 patients (32 percent) had subclinical
seizure activity detected by electroencephalogram [16].
Symptoms Many of the initial symptoms in patients with acute liver failure are nonspecific [14]. They include:
Other physical examination findings Other findings on physical examination in patients with acute liver
Fatigue/malaise
failure may include:
Lethargy
Anorexia Jaundice, which is a common finding in patients with acute liver failure but may be absent early in the
Nausea and/or vomiting course of acetaminophen poisoning or herpes simplex virus infection [2]
Right upper quadrant pain Vesicular skin lesions suggestive of herpes simplex virus (present in 30 to 50 percent of patients with acute
liver failure due to herpes simplex virus) [2,17]
Pruritus
Fever in patients with herpes simplex virus (reported in 82 percent of patients in one review) [17]
Jaundice
Right upper quadrant tenderness and hepatomegaly
Abdominal distension from ascites
Ascites
As the liver failure progresses, patients who were initially anicteric may develop jaundice, and those with subtle Signs of intravascular volume depletion, such as orthostatic hypotension
mental status changes (eg, lethargy, difficulty sleeping) may become confused or eventually comatose.
Laboratory test abnormalities Laboratory test abnormalities typically seen in patients with acute liver failure
Physical examination findings include:

Neurologic examination The presence of hepatic encephalopathy is one of the defining characteristics of Prolonged prothrombin time, resulting in an INR 1.5 (this finding is part of the definition of acute liver failure
acute liver failure. Findings in patients with hepatic encephalopathy are variable, ranging from changes in and thus must be present); hemostasis when measured by thromboelastography is normal [18,19].
behavior to coma. Hepatic encephalopathy is graded from I to IV (table 3 and figure 2) (see "Hepatic
encephalopathy in adults: Clinical manifestations and diagnosis"): Elevated aminotransferase levels (often markedly elevated).

Grade I: Changes in behavior, mild confusion, slurred speech, disordered sleep Elevated bilirubin level.
Grade II: Lethargy, moderate confusion Low platelet count (150,000/mm3).
Grade III: Marked confusion (stupor), incoherent speech, sleeping but wakes with stimulation
Grade IV: Coma, unresponsive to pain Decreasing aminotransferase levels may indicate spontaneous recovery but could also signal worsening of the
liver failure with loss of hepatocyte mass. In patients who are improving, the bilirubin and prothrombin time/INR
Patients with grade I encephalopathy may have mild asterixis, whereas pronounced asterixis is typically seen in will decline, whereas in those with worsening liver failure, the bilirubin and prothrombin time/INR will continue to
patients with grade II or III encephalopathy [5]. Asterixis is typically absent in patients with grade IV rise. Because of the prognostic importance of the prothrombin time/INR, it is recommended that products such
encephalopathy, who instead may demonstrate decorticate or decerebrate posturing.

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as plasma only be used when there is a clear indication [2]. In addition, despite an abnormal INR, patients may Ischemic hepatic injury: Very high aminotransferase levels (25 to 250 times the upper limit of normal),
not be hypocoagulable. In a study of 20 patients with acute liver failure, thromboelastography suggested a elevated serum LDH levels (see "Ischemic hepatitis, hepatic infarction, and ischemic cholangiopathy",
hypocoagulable state in 20 percent, normal coagulation in 45 percent, and a hypercoagulable state in 35 percent section on 'Clinical manifestations')
[20]. (See "Acute liver failure in adults: Management and prognosis", section on 'Bleeding prevention' and
Hepatitis B: Aminotransferase levels of to 1000 to 2000 international units/L are common, alanine
"Hemostatic abnormalities in patients with liver disease", section on 'Bleeding' and "Hemostatic abnormalities in
aminotransferase (ALT) level that is higher than the aspartate aminotransferase (AST) level (see "Clinical
patients with liver disease", section on 'Invasive procedure'.)
manifestations and natural history of hepatitis B virus infection", section on 'Acute hepatitis')
Other laboratory findings that may be seen in patients with acute liver failure include [5]:
Wilson disease: Coombs-negative hemolytic anemia, aminotransferase levels <2000 international units/L,
Anemia AST to ALT ratio of >2, normal or markedly subnormal alkaline phosphatase (<40 international units/L),
Elevated serum creatinine and blood urea nitrogen alkaline phosphatase (international units/L) to total bilirubin (mg/dL) ratio <4, rapidly progressive renal
Elevated amylase and lipase failure, low uric acid levels (see "Wilson disease: Clinical manifestations, diagnosis, and natural history",
Hypoglycemia section on 'Acute hepatitis and acute liver failure')
Hypophosphatemia Acute fatty liver of pregnancy/HELLP syndrome: Aminotransferase levels <1000 international units/L,
Hypomagnesemia elevated bilirubin, low platelet count (see "Acute fatty liver of pregnancy", section on 'Clinical manifestations'
Hypokalemia and "HELLP syndrome")
Acidosis or alkalosis
Herpes simplex virus: Markedly elevated transaminases, leukopenia, low bilirubin
Elevated ammonia level
Elevated lactate dehydrogenase (LDH) level Reye syndrome, valproate toxicity, or tetracycline toxicity: Minor to moderate elevations in aminotransferase
and bilirubin levels [5]
Acute kidney injury complicates acute liver failure in approximately 30 to 70 percent of patients [15,21-23]. The
frequency of renal injury is higher (up to 75 percent) for etiologies of acute liver failure that are known to Imaging and other studies Abdominal computed tomography (CT) in a patient with acute liver failure often
independently damage the kidneys, such as acetaminophen intoxication [11,23,24]. In one series of 1604 reveals a liver that appears less dense than skeletal muscle [25]. Other findings may include heterogenous liver
patients with acute liver failure, some degree of acute kidney injury developed in 70 percent of the patients, with parenchyma, hepatomegaly, ascites, evidence of malignant infiltration, and evidence of hepatic vein occlusion.
30 percent receiving renal replacement therapy [23]. Cirrhosis may be present in patients with acute liver failure due to Wilson disease, vertically transmitted hepatitis
B, or autoimmune hepatitis and may result in a nodular-appearing liver on imaging. However, a massively
The pathogenesis of renal injury in patients with acute liver failure is incompletely understood, but may be related
necrotic liver may also appear nodular due to parenchymal collapse [26]. However, because of the risk of renal
to systemic and intrarenal hemodynamic changes similar to those seen in hepatorenal syndrome. The clinical
failure with the intravenous contrast used for CT, ultrasound with Doppler imaging is often preferred for the
picture is similar in that the urine sodium concentration and fractional excretion are very low in the absence of
evaluation of acute liver failure. (See 'Imaging studies' below.)
diuretic therapy or tubular injury (as might be induced by acetaminophen), and the urine sediment shows few or
no cells or casts in the absence of marked hyperbilirubinemia. The blood urea nitrogen concentration may not be Neuroimaging (head CT or magnetic resonance imaging) in patients with acute liver failure may reveal evidence
a sensitive test to follow renal function in patients with acute liver failure since hepatic production of urea is of cerebral edema, including a decrease in the size of the ventricles, flattening of cerebral convolutions, and
decreased. (See "Hepatorenal syndrome".) attenuation of the signal intensity of brain parenchyma [27]. An electroencephalogram may reveal seizure
activity, even in the absence of clinical signs of seizures [16].
Laboratory findings associated with specific diagnoses Laboratory test findings often vary depending
upon the specific cause of the acute liver failure. Patterns seen on laboratory testing may suggest a diagnosis, Pulmonary edema and pulmonary infections develop in approximately 30 percent of patients with acute liver
but additional laboratory and imaging testing is required prior to making a diagnosis. These patterns should not failure and may be seen on chest radiographs [15]. (See "Clinical manifestations and diagnosis of edema in
be used to rule in or rule out a given diagnosis. (See 'Diagnosis' below.) adults", section on 'Pulmonary edema' and "Diagnostic approach to community-acquired pneumonia in adults",
section on 'Radiologic evaluation'.)
Some patterns that may be seen include [2]:
DIAGNOSIS
Acetaminophen: Very high aminotransferase levels (>3500 international units/L), low bilirubin, high INR (see
"Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and diagnosis", section Diagnosing acute liver failure Acute liver failure should be in the differential diagnosis of patients with the
on 'Clinical manifestations') recent onset (<26 weeks) of mental status changes, jaundice, or right upper quadrant pain. It should also be

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considered in patients with nonspecific symptoms such as nausea, vomiting, and malaise. The evaluation of be able to provide useful information, even if the patient is not able to.
such patients should include serum liver tests (aspartate aminotransferase [AST], alanine aminotransferase
Patients and/or their families should be asked about:
[ALT], alkaline phosphatase, gamma-glutamyl transpeptidase [GGT], total and direct bilirubin, albumin). If the
liver tests are abnormal, the patient's prothrombin time/INR should also be measured. (See 'Symptoms' above.) Timing of symptom onset (eg, malaise, nausea, vomiting, jaundice, mental status changes).

Acute liver failure is diagnosed by demonstrating all of the following: History of alcohol use.
Elevated aminotransferases (often with abnormal bilirubin and alkaline phosphatase levels) (see 'Laboratory History of prior episodes of jaundice.
test abnormalities' above)
Hepatic encephalopathy (see 'Neurologic examination' above) Medication use, including all medications used, the amounts ingested, and the durations of use. Medication
Prolonged prothrombin time (INR 1.5) (see 'Laboratory test abnormalities' above) use is not limited to prescription medications, but also includes over-the-counter medications, herbal and
dietary supplements, and illicit drug use.
Determining the cause of acute liver failure A cause for acute liver failure can be established in
approximately 60 to 80 percent of patients [4]. Identifying the underlying cause of the liver failure is important Risk factors for intentional drug overdose, such as a history of depression or prior suicide attempts.
because it influences the approach to management and provides prognostic information. A diagnosis is typically Toxin exposure, including occupational toxin exposures or wild mushroom ingestion.
made with a combination of history taking, laboratory tests, and imaging studies. If the initial evaluation fails to
identify an etiology, a liver biopsy may be required. Risk factors for acute viral hepatitis, including travel to areas endemic for hepatitis A or E, intravenous drug
use, occupational exposure, sexual exposure, chronic or inactive hepatitis B infection, and
Empiric therapy is often started along with the diagnostic workup if a particular cause is likely based upon history
immunosuppression.
or examination findings. This is especially true in patients with suspected acetaminophen-associated acute liver
failure since the treatment, N-acetylcysteine (NAC), significantly improves outcomes if started early and has few Risk factors for hepatic ischemia, including hypotension, cardiac failure, a hypercoagulable disorder, oral
side effects. NAC has also been used for patients with non-acetaminophen induced liver failure. Once the cause contraceptive use, or malignancy.
of the liver failure is confirmed, therapy can be adjusted as needed. (See 'Laboratory findings associated with
Family history of liver disease such as Wilson disease.
specific diagnoses' above and "Acute liver failure in adults: Management and prognosis", section on 'Treatment
of the underlying cause'.) In patients who develop acute liver failure while hospitalized, the patient's records should be reviewed for
possible causes including medications the patient has received (including anesthetics and immunosuppressants)
Timing of the evaluation The evaluation of a patient diagnosed with acute liver failure should begin
and episodes of hypotension or cardiac dysfunction.
immediately to identify the cause of the acute liver failure. This is crucial because in some cases, early diagnosis
and treatment may improve the patient's prognosis. In addition, timely evaluation is required to identify patients Physical examination Physical examination findings may help identify a cause of a patient's acute liver
who may require urgent liver transplantation. (See "Acute liver failure in adults: Management and prognosis", failure, but in many cases the findings, such as jaundice or hepatomegaly, are nonspecific. The physical
section on 'Treatment of the underlying cause'.) examination may also help identify complications of acute liver failure, such as cerebral edema and infection.
(See 'Physical examination findings' above.)
Laboratory tests and abdominal imaging should be ordered as soon as acute liver failure is recognized and
should not be delayed while the history and physical examination are being performed. Likewise, because All patients should have a routine physical examination, including a complete skin examination. In addition,
patients with grade I or II encephalopathy may progress to higher grade encephalopathy and lose their ability to patients suspected of having Wilson disease should undergo an ocular slit-lamp examination. (See "Wilson
communicate, a history should be obtained as soon as possible from such patients. disease: Clinical manifestations, diagnosis, and natural history", section on 'When to consider Wilson disease'.)
The initial evaluation should not be delayed in patients who are being transferred to a liver transplant center. Physical examination findings that may point to a specific cause of acute liver failure include:
Instead, the diagnostic evaluation should be initiated at the facility where the patient presents, with results
communicated to the transplant center as they become available. Conversely, transfer should not be delayed Vesicular skin lesions (herpes simplex virus)
because test results are still pending, because some patients (particularly those with cerebral edema) will quickly Kayser-Fleisher rings (Wilson disease) (picture 1)
become too unstable. Features of preeclampsia, such as hypertension (HELLP syndrome) (table 4 and table 5)

History A thorough history may identify potential causes for a patient's acute liver failure, but in patients Laboratory evaluation An extensive laboratory evaluation is required in patients with acute liver failure to
with severe encephalopathy, the history may be limited or unavailable. In some cases, the patient's family may determine the cause, assess the severity, and prepare for possible liver transplantation. Because patients with

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acute liver failure may decompensate rapidly, testing should not be delayed. (See 'Timing of the evaluation' who have any of the following:
above.)
A Coombs-negative hemolytic anemia
Laboratory tests that should be obtained at presentation include [2]: Neurologic symptoms prior to the onset of acute liver failure
Kayser-Fleisher rings
Prothrombin time/INR
A ratio of AST to ALT of greater than two
Serum chemistries (sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose, A normal or subnormal alkaline phosphatase
calcium, magnesium, phosphate, lactate dehydrogenase) A ratio of alkaline phosphatase (international units/L) to total bilirubin (mg/dL) of less than four

Liver blood tests (AST, ALT, alkaline phosphatase, GGT, total and direct bilirubin, albumin) Anti-hepatitis D virus antibodies in patients with acute or chronic hepatitis B. (See "Diagnosis of hepatitis D
virus infection", section on 'Diagnosis of HDV infection'.)
Complete blood count
Anti-hepatitis E virus antibodies for patients with travel to endemic areas such as Russia, Pakistan, Mexico,
Acetaminophen level
or India. (See "Hepatitis E virus infection", section on 'Diagnosis'.)
Toxicology screen
Urinalysis to look for proteinuria in women who are pregnant.
Viral hepatitis serologies (anti-hepatitis A IgM, hepatitis B surface antigen, anti-hepatitis B core IgM, anti-
Imaging studies Imaging with abdominal Doppler ultrasonography should be obtained to look for evidence
hepatitis C virus antibodies, hepatitis C RNA, anti-herpes simplex virus antibodies, anti-varicella zoster
of Budd-Chiari syndrome, portal hypertension, hepatic steatosis, hepatic congestion, and underlying cirrhosis.
antibodies; anti-hepatitis E IgM in women who are pregnant)
Ultrasonography is readily available, inexpensive, and noninvasive. Hepatic imaging may also reveal evidence of
Serum pregnancy test in women of childbearing potential who are not already known to be pregnant malignant infiltration. As noted above, a massively necrotic liver may appear nodular and does not necessarily
indicate underlying cirrhosis. (See "Budd-Chiari syndrome: Epidemiology, clinical manifestations, and diagnosis",
Autoimmune markers (antinuclear antibody, antismooth muscle antibody, anti-liver/kidney microsomal section on 'Diagnosis' and 'Imaging and other studies' above.)
antibody type 1, immunoglobulin levels)
Alternatives to ultrasound included abdominal computed tomography (CT) scanning, venography, or magnetic
Arterial blood gas resonance imaging and venography (MRI/MRV). In addition to being able to detect Budd-Chiari syndrome, CT
Arterial lactate and MRI are more sensitive than ultrasound for diagnosing hepatic malignancies. However, prior to obtaining a
CT scan, venogram, or MRI/MRV, the risk of renal injury associated with the contrast agents (contrast-induced
Arterial ammonia nephropathy with iodinated contrast agents and nephrogenic systemic fibrosis with gadolinium) should be
weighed against the need for the examination, especially since patients with acute liver failure may also have
Blood type and screen
renal failure. We reserve the use of these imaging techniques to patients with a negative ultrasound in whom the
Serologic testing for HIV suspicion for Budd-Chiari syndrome or malignancy remains high. (See "Pathogenesis, clinical features, and
diagnosis of contrast-induced nephropathy" and "Principles of magnetic resonance imaging", section on 'MR
Amylase and lipase contrast agent'.)

Additional tests that are indicated in specific circumstances include: An echocardiogram to look for cardiac dysfunction should be considered in patients suspected of having acute
hepatic ischemia without a known cause (eg, in a patient with markedly elevated transaminases without a cause
Ceruloplasmin level in patients suspected of having Wilson disease. However, serum ceruloplasmin may be
identified from the patient's history, laboratory examination, or abdominal imaging).
normal or elevated in the setting of acute liver failure, so if there is significant concern for Wilson disease, a
liver biopsy may be required. However, since most patients with acute liver failure due to Wilson disease will Liver biopsy If laboratory and imaging tests fail to identify an etiology, a liver biopsy may aid with the
need emergent liver transplantation, liver biopsies are usually not necessary if the liver failure is due to diagnosis. It is often performed via a transjugular approach in the setting of acute liver failure because of
Wilson disease, and transplantation should not be delayed in order to obtain biopsies. (See "Wilson disease: concerns over bleeding. Our practice is to obtain a liver biopsy in patients with acute liver failure of indeterminate
Clinical manifestations, diagnosis, and natural history", section on 'Diagnosis'.) etiology. However, if the patient has progressed to the point of requiring liver transplantation, histologic
evaluation can instead be performed on the explanted liver. (See "Transjugular liver biopsy".)
We obtain testing for Wilson disease in patients with acute liver failure who are under the age of 40 years or

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Liver biopsy may help with the diagnosis of: liver disease. While the time course that differentiates acute liver failure from chronic liver failure varies
between reports, a commonly used cutoff is an illness duration of <26 weeks. (See 'Definitions' above.)
Malignant infiltration.
Acute liver failure can result from a wide variety of causes, including (table 1 and table 2) [2,5] (see 'Etiology'
Autoimmune hepatitis. (See "Autoimmune hepatitis: Clinical manifestations and diagnosis", section on
above):
'Histology'.)
Acetaminophen (paracetamol)
Wilson disease. (See "Wilson disease: Diagnostic tests", section on 'Liver biopsy'.)
Idiosyncratic drug reactions
Hepatitis due to herpes simplex virus. Viral hepatitis
Autoimmune hepatitis
Acute fatty liver of pregnancy. However, because liver biopsy is invasive, it should be approached with
Wilson disease
caution during pregnancy and reserved for cases in which a diagnosis of acute fatty liver of pregnancy is in
Ischemic hepatopathy
doubt and the appropriate treatment (delivery) is being delayed. (See "Acute fatty liver of pregnancy",
Budd-Chiari syndrome
section on 'Liver biopsy'.)
Veno-occlusive disease
DIFFERENTIAL DIAGNOSIS The primary entity in the differential diagnosis of acute liver failure is severe Acute fatty liver of pregnancy/HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome
acute hepatitis. Patients with severe acute hepatitis have jaundice and coagulopathy but lack signs of hepatic Malignant infiltration
encephalopathy. Distinguishing the two is important because patients with severe acute hepatitis generally have
Partial hepatectomy
a good prognosis, whereas those who progress to acute liver failure have a high mortality rate and often require
Mushroom poisoning
liver transplantation [5].
Sepsis
Differentiating severe acute hepatitis from acute liver failure in a patient with Wilson disease may be difficult Heat stroke
because neurologic Wilson disease may be confused with hepatic encephalopathy. Features that suggest
neurologic Wilson disease rather than hepatic encephalopathy include the presence of dysarthria, dystonia, Viral and drug-induced hepatitis are the most common causes of acute liver failure in adults. (See 'Etiology'
tremors, or parkinsonism. In addition, neurologic symptoms in a patient with Wilson disease may have been above.)
present prior to the onset of the hepatic manifestations. (See "Wilson disease: Clinical manifestations, diagnosis, Clinical manifestations of acute liver failure in addition to hepatic encephalopathy, abnormal liver blood tests,
and natural history", section on 'Neurologic manifestations'.)
and an INR 1.5 (all of which are required for the diagnosis), may include jaundice, hepatomegaly, right
Patients with severe acute alcoholic hepatitis may present with liver failure that appears to have developed over upper quadrant tenderness, and thrombocytopenia. (See 'Clinical manifestations' above.)
the course of weeks to months [28]. However, patients with alcoholic hepatitis typically have a history of heavy Determining the etiology of acute liver failure requires a combination of history taking, laboratory tests, and
drinking for many years and are thus thought to have acute-on-chronic liver failure [29]. Differentiating alcoholic
imaging studies. If the initial evaluation fails to identify an etiology, a liver biopsy may be required. (See
hepatitis from acute liver failure is important because the two entities are managed differently (eg, there is a role
'Diagnosis' above.)
for corticosteroids in the treatment of alcoholic hepatitis, but not in acute liver failure). (See "Prognosis and
management of alcoholic fatty liver disease and alcoholic cirrhosis".) Because patients may decompensate rapidly, the initial evaluation should be broad, even in patients with a
presumed cause for their acute liver failure. A broad evaluation is required to identify a cause of the acute
Alcoholic hepatitis should be considered in patients with a history of heavy alcohol use or who have an aspartate
liver failure and to prepare for possible liver transplantation.
aminotransferase to alanine aminotransferase ratio of approximately 2:1. However, a history of heavy alcohol
use does not exclude other causes of acute liver failure (and in the case of acetaminophen toxicity may Laboratory tests that should be obtained at presentation include (see 'Laboratory evaluation' above):
predispose to it), so a patient presenting with acute liver failure in the setting of heavy alcohol use still requires a
Prothrombin time/INR
thorough evaluation. (See "Alcoholic hepatitis: Clinical manifestations and diagnosis", section on 'Introduction'.)
Serum chemistries (sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose,
SUMMARY AND RECOMMENDATIONS
calcium, magnesium, phosphate, lactate dehydrogenase)
Acute liver failure refers to the development of severe acute liver injury with encephalopathy and impaired
synthetic function (international normalized ratio [INR] of 1.5) in a patient without cirrhosis or preexisting Liver blood tests (AST, ALT, alkaline phosphatase, GGT, total and direct bilirubin, albumin)

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Complete blood count studies' above.)

Acetaminophen level
Use of UpToDate is subject to the Subscription and License Agreement.
Toxicology screen

Viral hepatitis serologies (anti-hepatitis A IgM, hepatitis B surface antigen, anti-hepatitis B core IgM, REFERENCES
anti-hepatitis C virus antibodies, hepatitis C RNA, anti-herpes simplex virus antibodies, anti-varicella
1. Lee WM, Squires RH Jr, Nyberg SL, et al. Acute liver failure: Summary of a workshop. Hepatology 2008;
zoster antibodies)
47:1401.
Serum pregnancy test in women of childbearing potential who are not already known to be pregnant 2. http://www.aasld.org/practiceguidelines/Documents/AcuteLiverFailureUpdate2011.pdf (Accessed on August
08, 2012).
Autoimmune markers (antinuclear antibody, antismooth muscle antibody, anti-liver/kidney microsomal
antibody type 1, immunoglobulin levels) 3. Lee WM, Stravitz RT, Larson AM. Introduction to the revised American Association for the Study of Liver
Diseases Position Paper on acute liver failure 2011. Hepatology 2012; 55:965.
Arterial blood gas 4. Lidofsky SD. Liver transplantation for fulminant hepatic failure. Gastroenterol Clin North Am 1993; 22:257.
Arterial lactate 5. Gill RQ, Sterling RK. Acute liver failure. J Clin Gastroenterol 2001; 33:191.
6. Wright G, Wilmore S, Makanyanga J, et al. Liver transplant for adult hemophagocytic lymphohistiocytosis:
Arterial ammonia
case report and literature review. Exp Clin Transplant 2012; 10:508.
Blood type and screen 7. Lee WM. Etiologies of acute liver failure. Semin Liver Dis 2008; 28:142.

Serologic testing for HIV 8. O'Grady JG, Portmann B, Williams R. Fulminant hepatic failure. In: Diseases of the Liver, Schiff L, Schiff R
(Eds), Lippincott, Philadelphia 1993.
Amylase and lipase 9. Oketani M, Ido A, Tsubouchi H. Changing etiologies and outcomes of acute liver failure: A perspective from
Japan. J Gastroenterol Hepatol 2011; 26 Suppl 1:65.
Additional laboratory tests that are indicated in specific circumstances include:
10. Kemmer NM, Miskovsky EP. Hepatitis A. Infect Dis Clin North Am 2000; 14:605.
Ceruloplasmin level in patients suspected of having Wilson disease. However, serum ceruloplasmin
11. Hoofnagle JH, Carithers RL Jr, Shapiro C, Ascher N. Fulminant hepatic failure: summary of a workshop.
may be normal or elevated in the setting of acute liver failure, so if there is significant concern for Hepatology 1995; 21:240.
Wilson disease, a liver biopsy may be required. (See "Wilson disease: Clinical manifestations,
12. Wright TL, Mamish D, Combs C, et al. Hepatitis B virus and apparent fulminant non-A, non-B hepatitis.
diagnosis, and natural history", section on 'Diagnosis'.)
Lancet 1992; 339:952.
Anti-hepatitis D virus antibodies in patients with acute or chronic hepatitis B. (See "Diagnosis of 13. Chu CM, Yeh CT, Liaw YF. Fulminant hepatic failure in acute hepatitis C: increased risk in chronic carriers
hepatitis D virus infection", section on 'Diagnosis of HDV infection'.) of hepatitis B virus. Gut 1999; 45:613.

Anti-hepatitis E virus antibodies for patients with travel to endemic areas such as Russia, Pakistan, 14. Lee WM. Acute liver failure. N Engl J Med 1993; 329:1862.
Mexico, or India. (See "Hepatitis E virus infection", section on 'Diagnosis'.) 15. Muoz SJ. Difficult management problems in fulminant hepatic failure. Semin Liver Dis 1993; 13:395.
16. Ellis AJ, Wendon JA, Williams R. Subclinical seizure activity and prophylactic phenytoin infusion in acute
Urinalysis to look for proteinuria in women who are pregnant.
liver failure: a controlled clinical trial. Hepatology 2000; 32:536.
Imaging with abdominal Doppler ultrasonography, computed tomography (CT) scanning, venography, or 17. Kaufman B, Gandhi SA, Louie E, et al. Herpes simplex virus hepatitis: case report and review. Clin Infect
magnetic resonance imaging and venography (MRI/MRV) should be obtained to look for evidence of Budd- Dis 1997; 24:334.
Chiari syndrome. Hepatic imaging may also reveal evidence of malignant infiltration. However, CT scanning, 18. Schidt FV, Balko J, Schilsky M, et al. Thrombopoietin in acute liver failure. Hepatology 2003; 37:558.
venography, and MRI/MRV should be used with caution because the contrast agents used are associated
19. Stravitz RT, Lisman T, Luketic VA, et al. Minimal effects of acute liver injury/acute liver failure on hemostasis
with renal injury. We reserve the use of CT, venography, and MRI/MRV for patients with a negative
as assessed by thromboelastography. J Hepatol 2012; 56:129.
ultrasound in whom the suspicion for Budd-Chiari syndrome or malignancy remains high. (See 'Imaging
20. Agarwal B, Wright G, Gatt A, et al. Evaluation of coagulation abnormalities in acute liver failure. J Hepatol

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2012; 57:780. GRAPHICS

21. Caraceni P, Van Thiel DH. Acute liver failure. Lancet 1995; 345:163.
Mnemonic for causes of acute liver failure: The ABCs
22. O'Grady JG, Williams R. Acute liver failure. In: Gastrointestinal emergencies, Gilmore IT, Shields R (Eds),
WB Saunders, Eastbourne 1992. p.104. A Acetaminophen, hepatitis A, autoimmune hepatitis, Amanita phalloides (mushroom poisoning), adenovirus

23. Tujios SR, Hynan LS, Vazquez MA, et al. Risk factors and outcomes of acute kidney injury in patients with B Hepatitis B, Budd-Chiari syndrome
acute liver failure. Clin Gastroenterol Hepatol 2015; 13:352. C Cryptogenic, hepatitis C, CMV

24. Mas A, Rods J. Fulminant hepatic failure. Lancet 1997; 349:1081. D Hepatitis D, drugs and toxins

25. Shakil AO, Jones BC, Lee RG, et al. Prognostic value of abdominal CT scanning and hepatic E Hepatitis E, EBV
histopathology in patients with acute liver failure. Dig Dis Sci 2000; 45:334. F Fatty infiltration - acute fatty liver of pregnancy, Reye's syndrome
26. Poff JA, Coakley FV, Qayyum A, et al. Frequency and histopathologic basis of hepatic surface nodularity in G Genetic - Wilson disease
patients with fulminant hepatic failure. Radiology 2008; 249:518. H Hypoperfusion (ischemic hepatitis, SOS, sepsis), HELLP syndrome, HSV, heat stroke, hepatectomy,
27. Chavarria L, Alonso J, Rovira A, Crdoba J. Neuroimaging in acute liver failure. Neurochem Int 2011; hemophagocytic lymphohistiocytosis
59:1175. I Infiltration by tumor

28. Amini M, Runyon BA. Alcoholic hepatitis 2010: a clinician's guide to diagnosis and therapy. World J CMV: cytomegalovirus; EBV: Epstein-Barr virus; SOS: sinusoidal obstruction syndrome (veno-occlusive disease); HELLP:
Gastroenterol 2010; 16:4905. hemolysis, elevated liver enzymes, low platelets; HSV: herpes simplex virus.

29. Mochida S, Takikawa Y, Nakayama N, et al. Diagnostic criteria of acute liver failure: A report by the
Graphic 67925 Version 6.0
Intractable Hepato-Biliary Diseases Study Group of Japan. Hepatol Res 2011; 41:805.

Topic 3574 Version 25.0

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Methamphetamine
Some drugs, herbal products, and toxins associated with acute liver failure Monoamine oxidase inhibitors

Abacavir Methyldopa

Acetaminophen (paracetamol) Nicotinic acid

Alcohol Nitrofurantoin

Allopurinol Nonsteroidal anti-inflammatory drugs

Amiodarone Phenprocoumon

Amoxicillin Phenytoin

Aspirin Poison mushrooms (Amanita phalloides)

Carbamazepine Propylthiouracil

Carbon tetrachloride Pyrazinamide

Ciprofloxacin Rifampin

Cocaine Senecio

Comfrey Statins

Dapsone Sulfonamides

Didanosine Terbinafine

Dideoxyinosine Tetracycline

Disulfiram Tolcapone

Doxycycline Tricyclic antidepressants

Efavirenz Valproic acid

Gemtuzumab
Graphic 79913 Version 5.0
Gold

Greater celandine

Halothane

He Shon Wu

Herbalife

Hydroxycut

Isoflurane

Isoniazid

Itraconazole

Kava Kava

Ketoconazole

Labetalol

LipoKinetix

Ma Huang

MDMA (Ecstasy)

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Acetaminophen metabolism Grading system for hepatic encephalopathy

Grade Mental status Asterixis EEG

I Euphoria/depression Yes/no Usually normal

Mild confusion

Slurred speech

Disordered sleep

II Lethargy Yes Abnormal

Moderate confusion

III Marked confusion Yes Abnormal

Incoherent

Sleeping but arousable

IV Coma No Abnormal

Graphic 62922 Version 1.0

At therapeutic doses, 90 percent of acetaminophen is metabolized in the liver

to sulfate and glucuronide conjugates that are then excreted in the urine.
One-half of the remaining acetaminophen is excreted unchanged in the urine
and one-half is metabolized via the hepatic cytochrome P450 (CYP2E1,
CYP1A2, CYP3A4 subfamilies) mixed function oxidase pathway to N-acetyl-p-
benzoquinoneimine (NAPQI), which is hepatotoxic. With normal doses (blue
arrows), NAPQI is rapidly conjugated to hepatic glutathione, forming nontoxic
cysteine and mercaptate compounds that are excreted in the urine. With toxic
doses (red arrow), the sulfate and glucuronide pathways become saturated,
resulting in an increased fraction of acetaminophen being metabolized by
cytochrome P450 enzymes. Once glutathione stores are depleted, NAPQI
begins to accumulate and hepatic injury ensues.

Graphic 68213 Version 2.0

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Clinical features of hepatic encephalopathy Kayser-Fleischer ring

Kayser-Fleischer ring (arrow) in a patient with advanced neuropsychiatric

Wilson disease. The dense brown copper deposits encircle the iris. It is rare
to see Kayser-Fleischer rings without the aid of a slit lamp examination
because Wilson disease is usually recognized at an earlier stage when the
rings are not as prominent.

Courtesy of Marshall M Kaplan, MD.

Graphic 65925 Version 2.0

Diagram depicting the grade of hepatic encephalopathy and the clinical features associated with
advancing stages.

Data from: Conn HO, Lieberthal MM. The hepatic coma syndromes and lactulose. Lippincott Williams &
Wilkins, Baltimore 1979.

Graphic 70740 Version 5.0

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Criteria for the diagnosis of preeclampsia Findings which increase the certainty of the diagnosis of preeclampsia

Systolic blood pressure 140 mmHg or diastolic blood pressure 90 mmHg on two occasions at least Systolic blood pressure 160 mm Hg
four hours apart after 20 weeks of gestation in a previously normotensive patient
Diastolic blood pressure 110 mm Hg
If systolic blood pressure is 160 mmHg or diastolic blood pressure is 110 mmHg, confirmation within minutes is
Proteinuria occurring for the first time during pregnancy, especially if 2 g in 24 hours. A qualitative result of 2+
sufficient
or 3+ is also suggestive.
and
Serum creatinine >1.2 mg/dL (106 mmol/L)
Proteinuria 0.3 g in a 24-hour urine specimen or protein/creatinine ratio 0.3 (mg/mg)(30 mg/mmol)
Platelet count <100,000 cells per cubic millimeter
Dipstick 1+ if a quantitative measurement is unavailable
Evidence of microangiopathic hemolytic anemia (eg, elevated indirect bilirubin or lactic acid dehydrogenase)
OR
Elevated liver chemistries (eg, alanine aminotransferase or aspartate aminotransferase)
New-onset hypertension with the new onset of any of the following (with or without proteinuria):
Persistent headache or other cerebral or visual disturbances
Platelet count <100,000/microL
Persistent epigastric pain
Serum creatinine >1.1 mg/dL (97.2 micromol/L) or doubling of the creatinine concentration in the absence of
other renal disease Working group report on high blood pressure in pregnancy. National Instititutes of Health, Washington, DC 2000.

Liver transaminases at least twice the upper limit of the normal concentrations for the local laboratory Graphic 60502 Version 3.0

Pulmonary edema

Cerebral or visual symptoms (eg, new-onset and persistent headaches not responding to usual doses of
analgesics*; blurred vision, flashing lights or sparks, scotomata)

* Response to analgesia does not exclude the possibility of preeclampsia.

Adapted from: American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy.
Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on
Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.

Graphic 79977 Version 25.0

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Contributor Disclosures
Eric Goldberg, MD Nothing to disclose Sanjiv Chopra, MD, MACP Nothing to disclose Robert S Brown, Jr,
MD, MPH Grant/Research/Clinical Trial Support: Gilead; Bristol-Myers Squibb; Janssen; AbbVie; Merck;
[Hepatitis C, ALF (various direct-acting agents for HCV, bioartificial liver devices)]. Consultant/Advisory Boards:
Gilead; Bristol-Myers Squibb; Janssen; AbbVie; Merck; Vital Therapies [Hepatitis B and C, ALF (various direct-
acting agents for HCV, bioartificial liver devices)]. Kristen M Robson, MD, MBA, FACG Consultant/Advisory
Boards: Actavis Pharma Inc. [IBS-D (Eluxadoline)].

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

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