Acute liver failure

viral hepatitides, non-alcoholic fatty liver disease (as a component of the metabolic syndrome) and alcohol-related liver disease

• Hyperacute – in which encephalopathy occurs within seven days of jaundice.
• Acute – with an interval of eight to 28 days from jaundice to encephalopathy.
• Subacute – with encephalopathy occurring 28 days to 12 weeks after jaundice.

Cytochrome P450 enzymes convert ~5% of acetaminophen to N-acetyl p-benzoquinoneimine (NAPQI), a metabolite which is normally detoxified by conjugation with hepatic glutathione. Hepatocellular glutathione becomes rapidly depleted in overdose, and NAPQI persists, causing damage to cell membranes leading to hepatocyte death

•  in patients who are younger than 10 years or older than 40 years
• those who have causes other than acetaminophen toxicity or hepatitis A and B virus infection
• when there is a long period between the development of symptoms and encephalopathy
• Persistent acidosis
• INR >3.5
• increasing serum bilirubin and creatinine concentrations also suggest a worse prognosis in those with non-acetaminophen aetiologies.

• Infection.
• Metabolic disturbances (electrolyte abnormalities, excessive diuretic therapy or fluid restriction, excessive paracentesis, uraemia, alkalosis, anaemia, hypoxaemia).
• Gastrointestinal disturbances (haemorrhage, constipation, excessive protein load).
• Hepatic abnormalities (acute liver necrosis, disease progression, portal vein thrombosis, ischaemia, hepatoma, spontaneous portosystemic shunting that may not be associated with liver disease, TIPS or surgical shunts).
• Psychoactive drugs.
• Medication non-compliance.

• ammonia
• mercaptans
• gamma-aminobutyric acid
• endogenous benzodiazepines
• serotonin/tryptophan.

• Grad 1: Konzentrationsstörungen, Stimmungsschwankungen, Probleme beim Lösen einfacher Rechenaufgaben.
• Grad 2: vermehrte Schläfrigkeit und eingeschränkte zeitliche Orientierung.
• Grad 3: Somnolenz, unzusammenhängende Sprache bei Erwecken
• Grad 4: Coma hepaticum (Leberkoma)