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{{Acute liver failure}}
{{Acute liver failure}}
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==Overview==
==Overview==
Acute liver failure results from the loss of normal function of hepatic tissue occurring over a short period of time. It results from the loss of the metabolic, secretory, and regulatory effects of the liver cells. This leads to the rapid accumulation of toxic substances, which then manifests in the patient as an altered [[sensorium]], [[cerebral edema]], [[hemodynamic]] abnormalities, and even [[multiorgan failure]].
Acute liver failure is a sudden and severe loss of liver function with evidence of [[encephalopathy]] and [[coagulopathy]] with elevated [[prothrombin time (PT)]] and [[INR|(INR)]] in a person without a preexisting [[liver disease]]. The consequences of acute liver failure are due to the loss of its [[metabolic]], secretory and regulatory effects. This results in the accumulation of [[toxic substances]] and causes deleterious effects. The major pathophysiological mechanisms of morbidity and mortality in patients with acute liver failure are [[cerebral edema]], [[hypoperfusion]] to the liver, [[idiosyncratic drug reactions]], depletion of [[glutathione]] and [[viral hepatitis]]. [[Cerebral edema]] in acute liver failure can be due to [[Vasogenic edema|vasogenic]] and [[cytotoxic]] effects. In [[cytotoxic]] type, there is [[Intracellular|intracellula<nowiki/>r]] swelling but [[blood-brain barrier]] is intact. In [[Vasogenic edema|vasogenic type]], the [[blood-brain barrier]] breaks down and plasma and water accumulate in the [[extracellular space]]. The increased [[ammonia]] concentration in liver failure in combination with the [[glutamine]] produced by the [[astrocytes]] causes excess levels of [[glutamine]] with the help of enzyme [[glutamine synthetase]]. The excess [[glutamine]] is [[cytotoxic]] and may influence the osmotic gradient which could result in [[brain edema]]. In acute liver failure, the increased levels of [[nitric oxide]] in the circulation can also disrupt the [[Autoregulation|cerebral autoregulation]]. [[Acetaminophen]] is the leading cause of acute liver failure in the United States. [[Acetaminophen]] causes dose-related [[toxicity]]. [[Toxicity]] is rarely seen at normal therapeutic doses (up to 4 g/day) without underlying [[liver disease]]. [[Viral hepatitis]] is the leading cause of acute liver failure in the developing world. [[Hepatitis A]], [[Hepatitis B|B]], [[Hepatitis D|D]] (associated with B), and [[Hepatitis E|E]] (in [[endemic]] countries) are commonly associated with acute liver failure.


==Pathophysiology==
==Pathophysiology==
Acute liver failure is caused by extensive damage to the liver tissue, causing severe compromise of its function. The effects of [[acute liver failure]] are due to the loss of its metabolic, secretory and regulatory effects. This results in the accumulation of [[toxic]] substances and causes deleterious effects. The major cause of [[morbidity]] and [[mortality]] in patients with liver failure are due to the development of [[cerebral edema]] which causes [[altered sensorium]] and [[increased intracranial pressure]]. [[Cerebral edema]] occurs due to damage to the [[blood brain barrier]]. Acute liver failure causes [[Hyperammonemia|increased ammonia concentrations]] due to failure of the detoxification system that occurs through the liver. The increased levels of [[ammonia]] in combination with the [[glutamate]] produced by the [[astrocytes]] of brain, causes excess levels of glutamine produced through the enzyme [[glutamine synthetase]]. The accumulation of glutamine in high concentrations in the brain is what causes [[cerebral edema]]. In acute liver failure, there are also increased levels of nitric oxide in the circulation. Nitric oxide is a potent vasodilator, and causes a disruption of the cerebral blood flow. This in turn disrupts [[cerebral auto-regulation]]. [[Multiorgan failure]] occurs due to severe [[hypotension]] which is caused by the decreased [[systemic vascular resistance]].
Acute liver failure is a sudden and severe loss of liver function with evidence of [[encephalopathy]] and [[coagulopathy]] with elevated [[prothrombin time (PT)]] and [[INR|(INR)]] in a person without preexisting [[liver disease]].
 
* The effects of [[acute liver failure]] are due to the loss of its [[metabolic]], secretory and regulatory effects. This results in the accumulation of [[toxic]] substances and causes deleterious effects.
* The major [[Pathophysiology|pathophysiological]] mechanisms of [[morbidity]] and [[mortality]] in patients with acute liver failure are [[cerebral edema]], [[hypoperfusion]] to the liver, [[idiosyncratic drug reactions]], depletion of [[glutathione]], and [[viral hepatitis]].  
*  [[Cerebral edema]] in acute liver failure can be due to [[Vasogenic edema|vasogenic]] and [[Cytotoxic|cytotoxic effects]].
* In [[Cytotoxic|cytotoxic type]], there is [[Intracellular|intracellular swelling]] but [[blood-brain barrier]] is intact.
* In [[Vasogenic edema|vasogenic type]], the [[blood-brain barrier]] breaks down and plasma and water accumulate in the [[extracellular space]].
* The increased [[ammonia]] concentration in liver failure in combination with the [[glutamine]] produced by the [[astrocytes]] causes excess levels of [[glutamine]] with the help of enzyme [[glutamine synthetase]]. The excess [[glutamine]] is [[cytotoxic]] and can disturb the [[osmotic]] gradient which can result in [[brain edema]].
* In acute liver failure, the increased levels of [[nitric oxide]] in the circulation can also disrupt the cerebral [[autoregulation]].
===Specific Conditions===
===Specific Conditions===
====Acetaminophen Toxicity====
====Acetaminophen Toxicity====
* [[Acetaminophen]] is the leading cause of acute liver failure.
* [[Acetaminophen]] is the leading cause of acute liver failure in the United States.
* Acetaminophen causes dose related toxicity.
* [[Acetaminophen]] causes dose-related [[toxicity]].
* Toxic doses can be as low as 3-4 g/day but most toxic ingestion's are of >10 g/day.
* [[Toxicity]] is rarely seen at normal therapeutic doses (up to 4 g/day) without underlying liver disease.
 
* [[Acetaminophen]] is mainly metabolized (90 %) in the [[liver]] and its metabolic end products ([[sulfate]] and [[glucuronide]] conjugates) are then excreted in the urine.
*Remaining one half unmetabolized [[acetaminophen]] is excreted unchanged in the urine and rest is [[metabolized]] by [[cytochrome P450]] pathway to [[NAPQI|N-acetyl-p-benzoquinoneimine (NAPQI)]].
*[[NAPQI]] is [[hepatotoxic]] and converted to nontoxic [[cysteine]] and [[mercaptan]] compounds by [[Glutathione|hepatic glutathione]] which are then excreted in the urine.
*At [[toxic]] doses, the [[sulfate]] and [[glucuronide]] [[conjugation]] pathway are overwhelmed and led to increased [[acetaminophen]] to be metabolized by [[cytochrome P450]].
*At [[toxic]] doses, the [[glutathione]] stores are depleted and it led to excess unattended [[NAPQI]] which causes [[hepatotoxicity]].
====Other Drugs====
====Other Drugs====
* Drugs other than acetaminophen also cause acute liver failure.
* Drugs other than [[acetaminophen]] also cause acute liver failure.
* These constitute 13% of cases of acute liver failure in US. <ref name="pmid12484709">{{cite journal |author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=[[Annals of Internal Medicine]] |volume=137 |issue=12 |pages=947–54 |year=2002 |month=December |pmid=12484709 |doi= |url=http://www.annals.org/article.aspx?volume=137&page=947 |accessdate=2012-10-27}}</ref>
* These constitute 13% of cases of acute liver failure in US.<ref name="pmid12484709">{{cite journal |author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=[[Annals of Internal Medicine]] |volume=137 |issue=12 |pages=947–54 |year=2002 |month=December |pmid=12484709 |doi= |url=http://www.annals.org/article.aspx?volume=137&page=947 |accessdate=2012-10-27}}</ref>
* They cause idiosyncratic drug hepatotoxicity.
* They cause [[Idiosyncratic drug reaction|idiosyncratic drug hepatotoxicity]].
* They usually present within six months of drug initiation.
* They usually present within six months of drug initiation.
====Mushroom Poisoning====
====Mushroom Poisoning====
* This is mainly caused by the genus Amanita (Amanita phalloides).<ref name="pmid12887855">{{cite journal |author=Catalina MV, Núñez O, Ponferrada A, Menchén L, Matilla A, Clemente G, Bañares R |title=[Liver failure due to mushroom poisoning: clinical course and new treatment perspectives] |language=Spanish; Castilian |journal=[[Gastroenterología Y Hepatología]] |volume=26 |issue=7 |pages=417–20 |year=2003 |pmid=12887855 |doi= |url=http://www.elsevier.es/en/linksolver/ft/ivp/0210-5705/26/417 |accessdate=2012-10-27}}</ref>
* This is mainly caused by the genus [[Amanita]] ([[Amanita phalloides]]).<ref name="pmid12887855">{{cite journal |author=Catalina MV, Núñez O, Ponferrada A, Menchén L, Matilla A, Clemente G, Bañares R |title=[Liver failure due to mushroom poisoning: clinical course and new treatment perspectives] |language=Spanish; Castilian |journal=[[Gastroenterología Y Hepatología]] |volume=26 |issue=7 |pages=417–20 |year=2003 |pmid=12887855 |doi= |url=http://www.elsevier.es/en/linksolver/ft/ivp/0210-5705/26/417 |accessdate=2012-10-27}}</ref>
* Presentations may vary from case to case and it constitutes a [[medical emergency]].
* Presentations may vary from case to case and it constitutes a [[medical emergency]].
* Patients may recover from traditional medical treatment, or may require [[transplantation]] in more severe cases.
* Patients may recover from traditional medical treatment, or may require [[transplantation]] in more severe cases.
====Viral Hepatitis====
====Viral Hepatitis====
* [[Hepatitis A|Hepatitis viruses A]], [[Hepatitis B|B]], [[Hepatitis D|D]] (associated with B), and E (in endemic countries) can cause acute liver failure.
* [[Hepatitis A]], [[Hepatitis B|B]], [[Hepatitis D|D]] (associated with B), and [[Hepatitis E|E]] (in [[endemic]] countries) can cause acute liver failure in the developing world.
* [[Viral hepatitis]] (Hepatitis A and B) constitute to causing 12% of the cases of acute liver failure in US.<ref name="pmid12484709">{{cite journal |author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=[[Annals of Internal Medicine]] |volume=137 |issue=12 |pages=947–54 |year=2002 |month=December |pmid=12484709 |doi= |url=http://www.annals.org/article.aspx?volume=137&page=947 |accessdate=2012-10-27}}</ref>
* [[Viral hepatitis]] ([[Hepatitis A]] and [[Hepatitis B|B]]) constitute to causing 12% of the cases of acute liver failure in US.<ref name="pmid12484709">{{cite journal |author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM |title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States |journal=[[Annals of Internal Medicine]] |volume=137 |issue=12 |pages=947–54 |year=2002 |month=December |pmid=12484709 |doi= |url=http://www.annals.org/article.aspx?volume=137&page=947 |accessdate=2012-10-27}}</ref>
* [[Hepatitis C]] alone doesn't seem to cause [[acute liver failure]].<ref name="pmid12591067">{{cite journal |author=Schiødt FV, Davern TJ, Shakil AO, McGuire B, Samuel G, Lee WM |title=Viral hepatitis-related acute liver failure |journal=[[The American Journal of Gastroenterology]] |volume=98 |issue=2 |pages=448–53 |year=2003 |month=February |pmid=12591067 |doi=10.1111/j.1572-0241.2003.t01-1-07223.x |url=http://dx.doi.org/10.1111/j.1572-0241.2003.t01-1-07223.x |accessdate=2012-10-27}}</ref>
* [[Hepatitis C]] alone doesn't seem to cause [[acute liver failure]].<ref name="pmid12591067">{{cite journal |author=Schiødt FV, Davern TJ, Shakil AO, McGuire B, Samuel G, Lee WM |title=Viral hepatitis-related acute liver failure |journal=[[The American Journal of Gastroenterology]] |volume=98 |issue=2 |pages=448–53 |year=2003 |month=February |pmid=12591067 |doi=10.1111/j.1572-0241.2003.t01-1-07223.x |url=http://dx.doi.org/10.1111/j.1572-0241.2003.t01-1-07223.x |accessdate=2012-10-27}}</ref>
* There is a difference in the survival rate of patients with [[acute liver failure]] in [[hepatitis A]] and [[hepatitis B]] which cannot be explained by the severity of dysfunction, but may rather be an inherent feature of the [[infection]]s themselves.<ref name="pmid12591067">{{cite journal |author=Schiødt FV, Davern TJ, Shakil AO, McGuire B, Samuel G, Lee WM |title=Viral hepatitis-related acute liver failure |journal=[[The American Journal of Gastroenterology]] |volume=98 |issue=2 |pages=448–53 |year=2003 |month=February |pmid=12591067 |doi=10.1111/j.1572-0241.2003.t01-1-07223.x |url=http://dx.doi.org/10.1111/j.1572-0241.2003.t01-1-07223.x |accessdate=2012-10-27}}</ref>
* There is a difference in the survival rate of patients with [[acute liver failure]] in [[hepatitis A]] and [[hepatitis B]]. This may be an inherent feature of infections and does not depend on the severity of dysfunction.<ref name="pmid12591067">{{cite journal |author=Schiødt FV, Davern TJ, Shakil AO, McGuire B, Samuel G, Lee WM |title=Viral hepatitis-related acute liver failure |journal=[[The American Journal of Gastroenterology]] |volume=98 |issue=2 |pages=448–53 |year=2003 |month=February |pmid=12591067 |doi=10.1111/j.1572-0241.2003.t01-1-07223.x |url=http://dx.doi.org/10.1111/j.1572-0241.2003.t01-1-07223.x |accessdate=2012-10-27}}</ref>
 
====Autoimmune Hepatitis====
====Autoimmune Hepatitis====
* [[Autoimmune hepatitis]] may be an unrecognized coexistent condition.
* [[Autoimmune hepatitis]] may be an unrecognized coexistent condition.
* [[Autoantibodies]] are helpful in the diagnosis of the condition. In cases of a negative test for autoantibodies, [[biopsy]] may be required.
* [[Autoantibodies]] are helpful in the diagnosis of the condition. In cases of a negative test for autoantibodies, [[biopsy]] may be required.
* A few patients may need [[transplantation]] along with [[steroid]] therapy.
* A few patients may need [[transplantation]] along with [[steroid]] therapy.
====Ischemic Injury====
====Ischemic Injury====
* This condition is called [[shock liver]]. It is a common occurrence in the ICU with a prevalence of 10%.<ref name="pmid20361374">{{cite journal |author=Fuhrmann V, Jäger B, Zubkova A, Drolz A |title=Hypoxic hepatitis - epidemiology, pathophysiology and clinical management |journal=[[Wiener Klinische Wochenschrift]] |volume=122 |issue=5-6 |pages=129–39 |year=2010 |month=March |pmid=20361374 |doi=10.1007/s00508-010-1357-6 |url=http://dx.doi.org/10.1007/s00508-010-1357-6 |accessdate=2012-10-27}}</ref>
* This condition is called [[shock liver]]. It is a common occurrence in the ICU with a prevalence of 10%.<ref name="pmid20361374">{{cite journal |author=Fuhrmann V, Jäger B, Zubkova A, Drolz A |title=Hypoxic hepatitis - epidemiology, pathophysiology and clinical management |journal=[[Wiener Klinische Wochenschrift]] |volume=122 |issue=5-6 |pages=129–39 |year=2010 |month=March |pmid=20361374 |doi=10.1007/s00508-010-1357-6 |url=http://dx.doi.org/10.1007/s00508-010-1357-6 |accessdate=2012-10-27}}</ref>
* Shock liver results from severe [[hypotension]] due to any causes such as [[heart failure]], severe vaso-constriction due to drugs like [[niacin]] and [[cocaine]].
* Shock liver results from severe [[hypotension]] due to any causes such as [[heart failure]] or vasoconstictive drugs.
* Early recovery frequently occurs, but the long term outcome depends on the underlying cause of the [[ischemia]].
* Early recovery frequently occurs, but the long term outcome depends on the underlying cause of the [[ischemia]].
====HELLP Syndrome====
====HELLP Syndrome====
* Some women near the end of their pregnancy may develop rapidly progressive [[liver failure]].
* Some women near the end of their [[pregnancy]] may develop rapidly progressive [[liver failure]].
* [[HELLP syndrome]] conisists of the triad of [[hemolysis]], [[elevated liver enzymes]] and [[low platelet]]s.
* [[HELLP syndrome]] conisists of the triad of [[hemolysis]], elevated [[liver enzymes]] and [[Thrombocytopenia|low platelets]].
* Most of the patients will improve spontaneously with [[delivery]].
* Most of the patients will improve spontaneously with [[delivery]].
* [[Postpartum]] deterioration may require [[liver transplantation]].
* [[Postpartum]] deterioration may require [[liver transplantation]].
====Malignancy====
====Malignancy====
* Malignant infiltration may cause [[acute liver failure]].
* [[Malignant|Malignant infiltration]] may cause [[acute liver failure]].
* Severe acute infiltrations may occur with a few malignancies like [[breast cancer]], [[small cell lung cancer]], [[lymphoma]], [[melanoma]], and [[myeloma]].
* Severe acute infiltrations may occur with a few malignancies like [[breast cancer]], [[small cell lung cancer]], [[lymphoma]], [[melanoma]], and [[myeloma]].
* [[Transplantation]] is not advised in these patients.<ref name="pmid8200270">{{cite journal |author=Woolf GM, Petrovic LM, Rojter SE, Villamil FG, Makowka L, Podesta LG, Sher LS, Memsic L, Vierling JM |title=Acute liver failure due to lymphoma. A diagnostic concern when considering liver transplantation |journal=[[Digestive Diseases and Sciences]] |volume=39 |issue=6 |pages=1351–8 |year=1994 |month=June |pmid=8200270 |doi= |url= |accessdate=2012-10-27}}</ref>
* [[Transplantation]] is not advised in these patients.<ref name="pmid8200270">{{cite journal |author=Woolf GM, Petrovic LM, Rojter SE, Villamil FG, Makowka L, Podesta LG, Sher LS, Memsic L, Vierling JM |title=Acute liver failure due to lymphoma. A diagnostic concern when considering liver transplantation |journal=[[Digestive Diseases and Sciences]] |volume=39 |issue=6 |pages=1351–8 |year=1994 |month=June |pmid=8200270 |doi= |url= |accessdate=2012-10-27}}</ref>


===Pathology===
==Gross Pathology==
In the majority of acute liver failure (ALF) there is widespread hepatocellular necrosis beginning in the [[hepatic lobule|centrizonal distribution]] and progressing towards portal tracts. The degree of [[parenchyma]]l inflammation is variable and  is proportional to duration of [[disease]]<ref>{{cite journal |author=Boyer JL, Klatskin G |title=Pattern of necrosis in acute viral hepatitis. Prognostic value of bridging (subacute hepatic necrosis) |journal=N. Engl. J. Med. |volume=283 |issue=20 |pages=1063-71 |year=1970 |pmid=4319402 |doi=}}</ref>.
On gross [[pathology]], characteristic findings of acute liver failure include:
 
==Microscopic Pathology==
On microscopic [[pathology]], characteristic findings of acute liver failure include:<ref>[http://askdrwiki.com/mediawiki/index.php?title=Category:Pathology]</ref>
 
 
[[Image:Drug-induced hepat.gif|center|thumb|400px|Drug induced hepatitis <br>Soource:By Nephron (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons]]
 
{{#ev:youtube|G5G9AnVhqhI}}
 
{{#ev:youtube|l4m3f2KCxLM}}


==References==
==References==

Latest revision as of 17:03, 18 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [3] Husnain Shaukat, M.D [4]

Overview

Acute liver failure is a sudden and severe loss of liver function with evidence of encephalopathy and coagulopathy with elevated prothrombin time (PT) and (INR) in a person without a preexisting liver disease. The consequences of acute liver failure are due to the loss of its metabolic, secretory and regulatory effects. This results in the accumulation of toxic substances and causes deleterious effects. The major pathophysiological mechanisms of morbidity and mortality in patients with acute liver failure are cerebral edema, hypoperfusion to the liver, idiosyncratic drug reactions, depletion of glutathione and viral hepatitis. Cerebral edema in acute liver failure can be due to vasogenic and cytotoxic effects. In cytotoxic type, there is intracellular swelling but blood-brain barrier is intact. In vasogenic type, the blood-brain barrier breaks down and plasma and water accumulate in the extracellular space. The increased ammonia concentration in liver failure in combination with the glutamine produced by the astrocytes causes excess levels of glutamine with the help of enzyme glutamine synthetase. The excess glutamine is cytotoxic and may influence the osmotic gradient which could result in brain edema. In acute liver failure, the increased levels of nitric oxide in the circulation can also disrupt the cerebral autoregulation. Acetaminophen is the leading cause of acute liver failure in the United States. Acetaminophen causes dose-related toxicity. Toxicity is rarely seen at normal therapeutic doses (up to 4 g/day) without underlying liver disease. Viral hepatitis is the leading cause of acute liver failure in the developing world. Hepatitis A, B, D (associated with B), and E (in endemic countries) are commonly associated with acute liver failure.

Pathophysiology

Acute liver failure is a sudden and severe loss of liver function with evidence of encephalopathy and coagulopathy with elevated prothrombin time (PT) and (INR) in a person without preexisting liver disease.

Specific Conditions

Acetaminophen Toxicity

Other Drugs

Mushroom Poisoning

Viral Hepatitis

Autoimmune Hepatitis

Ischemic Injury

  • This condition is called shock liver. It is a common occurrence in the ICU with a prevalence of 10%.[4]
  • Shock liver results from severe hypotension due to any causes such as heart failure or vasoconstictive drugs.
  • Early recovery frequently occurs, but the long term outcome depends on the underlying cause of the ischemia.

HELLP Syndrome

Malignancy

Gross Pathology

On gross pathology, characteristic findings of acute liver failure include:

Microscopic Pathology

On microscopic pathology, characteristic findings of acute liver failure include:[6]


Drug induced hepatitis
Soource:By Nephron (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

{{#ev:youtube|G5G9AnVhqhI}}

{{#ev:youtube|l4m3f2KCxLM}}

References

  1. ↑ 1.0 1.1 Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM (2002). "Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States". Annals of Internal Medicine. 137 (12): 947–54. PMID 12484709. Retrieved 2012-10-27. Unknown parameter |month= ignored (help)
  2. ↑ Catalina MV, Núñez O, Ponferrada A, Menchén L, Matilla A, Clemente G, Bañares R (2003). "[Liver failure due to mushroom poisoning: clinical course and new treatment perspectives]". Gastroenterología Y Hepatología (in Spanish; Castilian). 26 (7): 417–20. PMID 12887855. Retrieved 2012-10-27.
  3. ↑ 3.0 3.1 Schiødt FV, Davern TJ, Shakil AO, McGuire B, Samuel G, Lee WM (2003). "Viral hepatitis-related acute liver failure". The American Journal of Gastroenterology. 98 (2): 448–53. doi:10.1111/j.1572-0241.2003.t01-1-07223.x. PMID 12591067. Retrieved 2012-10-27. Unknown parameter |month= ignored (help)
  4. ↑ Fuhrmann V, Jäger B, Zubkova A, Drolz A (2010). "Hypoxic hepatitis - epidemiology, pathophysiology and clinical management". Wiener Klinische Wochenschrift. 122 (5–6): 129–39. doi:10.1007/s00508-010-1357-6. PMID 20361374. Retrieved 2012-10-27. Unknown parameter |month= ignored (help)
  5. ↑ Woolf GM, Petrovic LM, Rojter SE, Villamil FG, Makowka L, Podesta LG, Sher LS, Memsic L, Vierling JM (1994). "Acute liver failure due to lymphoma. A diagnostic concern when considering liver transplantation". Digestive Diseases and Sciences. 39 (6): 1351–8. PMID 8200270. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  6. ↑ [1]

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