Acute liver failure differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Overview

There are some diseases or conditions which have a similar presentation to acute liver failure. These include tyrosenemia, fructose intolerance, being affected by the toxin from bacillus cereus, and the HELLP syndrome of pregnancy.

Differentiating Acute Liver Failure from other Diseases

Acute liver failure must be differentiated from other diseases that cause signs and symptoms of jaundice, coagulopathy, and encephalopathy.

Condition	Differentiating signs and symtoms	Differentiating Tests
Acute hepatits	Jaundice and coagulopathy may be present. Severe acute hepatitis is followed very closely as it has a potential to develop into acute or subacute hepatic failure. Acute hepatitis would not be considered acute liver failure unless hepatic encephalopathy is present.	Hepatic encephalopathy is absent. Grades of hepatic encephalopathy are: Grade 1 Grade 2 Grade 3 Grade 4
Cholestasis	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Hemolysis	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].

Abbreviations: RUQ= Right upper quadrant of the abdomen, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CT= Computed tomography

Classification of jaundice based on etiology Disease History and clinical manifestations Diagnosis Lab Findings Other blood tests Other diagnostic Family history Fever RUQ Pain Pruritis AST ALT ALK BLR Indirect BLR Direct Viral serology Jaundice Hepatocellular Jaundice Hemochromatosis + - -/+ - ↑ ↑ ↑/N ↑/N N - Ferritin ↑ Liver biopsy Wilson's disease + - -/+ - ↑ ↑ N ↑/N N - Serum cerulloplasmin ↑ Liver biopsy Viral hepatitis - -/+ - - ↑ ↑ N ↑/N N + Specific viral antibody for each type - Alcoholic hepatitis - - - - ↑ ↑↑ N ↑/N N - - - Drug induced hepatitis - -/+ - - ↑ ↑ N ↑/N N - - - Autoimmune hepatitis -/+ - - -/+ ↑ ↑ N ↑/N N - Anti-LKM antibody Liver biopsy Cholestatic Jaundice Common bile duct stone -/+ - + + N N ↑ ↑ N - Dilated ducts on sono CT/ERCP Hepatitis A cholestatic type - -/+ + + N N ↑ ↑ N + HAV- AB Abdominal ultrasound EBV / CMV hepatitis - -/+ + + N N ↑ ↑ N + Positive serology Primary biliary cirrhosis -/+ - -/+ + N/↑ N/↑ ↑ ↑ N - AMA positive Liver biopsy Primary sclerosing cholangitis -/+ - -/+ + N/↑ N/↑ ↑ ↑ N - Beading on MRCP Liver biopsy Isolated Jaundice Crigler-Najjar type 2 + - - - N N N ↑ N - Genetic testing Gilbert + - - - N N N ↑ N - Genetic testing Rotor syndrome + - - - N N N N ↑ - Genetic testing Liver biopsy Dubin-Johnson syndrome + - - - N N N N ↑ - Genetic testing Liver biopsy Hereditory spherocytosis + - -/+ - N N N ↑ N - Genetic testing Osmotic fragility G6PD deficiency + - - - N N N ↑ N - Genetic testing Thalassemia + - - - N N N ↑ N - Genetic testing Sickle cell disease + - - - N N N ↑ N - Genetic testing Paroxismal nocturnal hemoglobinoria - - - - N N N ↑ N - Flocytometery Immune hemolysis - -/+ - - N N N ↑ N - Autoantibodies Hematoma - -/+ - - N N N ↑ N - Anemia Truma or surgery in history