Liver Failure Signs

Liver is a reddish-brown, triangular organ located just below the diaphragm, in the abdominal cavity. It is the largest internal organ of the body, and is responsible for the synthesis and storage of glycogen, detoxification, bile synthesis, immune system regulation and several homeostatic and metabolic activities.

Liver failure implies a reduction in liver function owing to the dysfunction of hepatic cells. The major cause behind liver failure is structural damage that occurs due to excessive consumption of alcohol.

Other causes include drug toxicity, hepatitis, liver cancer, fatty liver disease as well as autoimmune diseases and certain genetic disorders like primary hemochromatosis, Wilson's disease, etc. Given below are the signs useful for identification and diagnosis of liver failure.

Early Symptoms of Liver Failure

• Nausea
• Fatigue
• Weight loss
• Loss of appetite
• Diarrhea
• Dry, itchy skin
• Easy bruising and bleeding

Liver failure occurs in two forms: acute and chronic. Acute liver failure refers to the sudden loss of liver function, whereas chronic liver failure is the result of a gradual decrease in liver function. Most often, individuals with liver failure remain asymptomatic or experience mild symptoms like abdominal pain, fatigue and nausea, which may go unnoticed.

These symptoms, when accompanied with the following signs, are indicative of liver failure.

» Palmar erythema
The reddening of palms, especially at the base of the thumb and little finger is called palmar erythema. It is often associated with chronic liver failure, and hence is also termed liver palms. Although it is not a distinctive sign for liver failure, it does serve as a useful marker.

» Xanthomatosis
It is characterized by the accumulation of lipids to form tiny, yellow-colored, flat bumps called xanthomas, under the skin. Such bumps are observed especially on the fingers, elbows, knees and other joints, as well as on the hands and feet. These may occur in case of altered lipid metabolism due to liver malfunction.

» Spider nevi
Spider angioma, vascular spider or spider nevus is characterized by the dilation of blood vessels near the skin surface. It appears like a lesion with central red spot, and radiating red extensions that resemble the web of a spider.

It is often observed on the neck, face, arms and upper part of the trunk. The presence of more than five spider nevi is considered to be a sign of liver failure.

» Ascites
It refers to a buildup of fluid in the peritoneal cavity, and is a result of low albumin and increased blood pressure in veins of the liver (portal hypertension). The initial stages of fluid buildup may be asymptomatic, but as the accumulation increases one may experience bloating and abdominal pain. Excessive buildup leads to abdominal distension and shortness of breath.

» Caput medusae
Portal hypertension leads to dilation of the paraumbilical veins that are present near the navel. As a result, these veins, which are otherwise barely visible through the skin surface, become very prominent and appear engorged and swollen.

They appear like blue tubular structures radiating from the navel, in a pattern that resembles the snakes of Medusa. Hence the name caput medusae (head of Medusa).

Malfunctioning of liver affects the levels several enzymes and metabolites present in blood. The resultant clinical signs are useful for confirming liver failure as well identification of the precise cause. Some of the prominent ones have been explained below.

» Low serum albumin
Albumin is a type of globular protein that accounts for half the protein content of serum. The normal levels of serum albumin for adults is 3.4 to 5.4 g/dL. It is synthesized in the liver, and hence abnormally low levels of this protein indicate a loss of liver function.

» High serum bilirubin
Bilirubin is a yellow-colored pigment obtained on the breakdown of red blood cells in spleen. This unconjugated bilirubin is water-insoluble and transported to the liver by albumin. Here, it is conjugated or chemically modified with the help of enzymes to make it water-soluble. This conjugated bilirubin is secreted as a component of bile.

Liver dysfunction hampers such conjugation of bilirubin leads to an increase in the levels of unconjugated bilirubin in blood. The reference range for conjugated and total bilirubin in blood is 0 to 0.3 mg/dL and 0.1 to 1.0 mg/dL respectively.

Mild elevation in the total bilirubin content of blood is indicative of chronic liver failure or cirrhosis, whereas a rapid progressive increase indicates acute liver failure. The increase in bilirubin is also manifested as jaundice (yellowing of skin, eyes, nails), dark urine. Altered bilirubin metabolism is also indicated by white or clay-colored stools.

» Serum enzymes
Liver failure is characterized by an alteration in the levels of certain enzymes present in blood. The levels of these enzymes are mostly checked as a part of liver function tests, and are indicative of liver damage rather than liver function.

A mild rise in the levels of these enzymes may occur under normal conditions, but such rise when accompanied with other physical and clinical signs provide confirmation for liver failure.

Enzyme (IU/L): ALT
Ref. Range (IU/L): 10 to 40
Acute Liver Failure: ↑↑↑
Chronic Liver Failure: ↑

Enzyme (IU/L): ALP
Ref. Range (IU/L): 44 to 147
Acute Liver Failure: ↑↑
Chronic Liver Failure: ↑

Enzyme (IU/L): AST
Ref. Range (IU/L): 10 to 34
Acute Liver Failure: ↑↑↑
Chronic Liver Failure: ↑

↑: Mild increase; ↑↑: Increase up to 5 times the upper limit; ↑↑↑: Increase up to 10-100 times the uper limit;
ALT: Alanine Transaminase (or aminotransferase); ALP: Alkaline Phosphatase; AST: Aspartate Transaminase (or aminotransferase); IU/L: International Units per Liter

In case of elevation of the above mentioned enzymes, the AST:ALT ratio is useful to understand the etiology behind liver failure. The normal value for this ratio is 1. Values between 1.0 and 2.0 indicate chronic liver failure, and values above 2.0 indicate liver cancer and alcoholic hepatitis.

» Abnormal blood sugar levels
Liver plays a crucial role in glucose and glycogen metabolism, and hence liver dysfunction disrupts glucose homeostasis. Acute liver failure is often associated with decrease in blood sugar level (hypoglycemia), whereas chronic liver failure leads to elevated blood sugar levels (hyperglycemia) and glucose intolerance.

» Electrolyte imbalance
Liver failure leads to a series of changes in kidney function, thereby disrupting the fluid and electrolyte balance of the body. It is often manifested as a decrease in the levels of sodium (hyponatremia), potassium (hypokalemia) and phosphate (hypophosphatemia).

Such imbalance also influences tissue pH leading to metabolic alkalosis. Hyponatremia also leads to water retention and tissue edema.

Severe Complications In case of significant tissue damage as well as persistence of the above-mentioned clinical conditions, severe complications may arise leading to coma or even death.

» Coagulation defects
One of the crucial functions of liver is to synthesize clotting factors, anti-coagulating factors as well as regulate the production of platelets.

Hence, loss of liver function leads to decreased platelet count, and alters the blood clotting process which is measured as prothrombin time and international normalized ratio (ratio of prothrombin time and normal mean prothrombin time).

Parameter	Ref. Range	Liver Failure
Platelet count	150,000 - 400,000 platelets/mcL	Low
PT	10 to 12 seconds	High
INR	0.8 to 1.2	High

PT: Prothrombin Time; INR: International Normalized Ratio; mcL:microliter

The early stages of liver failure are characterized by a normal platelet count but increased prothrombin time. However, as the liver damage and dysfunction increases, the platelet count falls below 150,000 platelets per microliter.

This results in easy bruising and bleeding as well as coagulopathy, a condition characterized by uncontrolled external or internal bleeding following an injury or medical procedure.

» Hepatic encephalopathy
Impaired liver function leads to a rise in the levels of ammonia in blood (normal range: 15-45 mcg/dL). The resulting toxicity hampers the regulation of cerebral blood flow leading to tissue injury and buildup of fluid in the intracellular and extracellular spaces of brain (cerebral edema).

This influences a set of nervous system functions and leads to abnormal mental status as well as abnormal hand movements. This is termed hepatic encephalopathy, which if untreated progresses to hepatic coma.

A prominent sign is the asterixis or liver flap, which is characterized by involuntary jerky movements of the hand when the arm is extended. Other symptoms include:

• Confusion
• Forgetfulness
• Brain fog
• Disorientation
• Sleep disorders
• Sluggish movements
• Drowsiness

• Slurred speech
• Difficulty in writing
• Irritability
• Mood changes
• Sweet/musty breath odor
• Poor judgment
• Poor concentration
• Inappropriate behavior

Liver problems often remain unnoticed, and the symptoms are experienced only after a significant tissue damage has occurred. Hence, it is essential to be aware about the signs of liver failure, and consult the appropriate medical expert for correct diagnosis of the underlying problem followed by a prompt treatment.

This story is for informative purposes only, and should not be used as a substitute for professional medical advice.