Acute liver failure is a life-threatening condition that occurs in patients who have no preexisting liver disease. The condition is characterized by liver injury, coagulopathy, and hepatic encephalopathy. The American College of Gastroenterology has issued clinical guidelines that provide a detailed approach to the diagnosis and management of acute liver failure, with emphasis on the importance of early recognition, prompt initiation of treatment, and referral to specialized care.

Acute liver failure has multiple etiologies and clinical presentations and can affect virtually all organ systems. In addition to the general management of the disease, the guidelines provide specific recommendations for system-specific and etiology-specific management.

Etiology is a key indicator of prognosis and treatment strategy, especially of the need for liver transplant, according to the guidelines. Without a transplant, the morbidity and mortality associated with acute liver failure is high. Timely referral to a transplant center is essential. It's also essential to distinguish between acute and acute-on-chronic liver failure because the management of each is significantly different.

Patients who have acute liver failure should be referred for hepatology or gastroenterology consultation as soon as possible. Those unlikely to survive with medical treatment alone need an early referral to a transplant center.

Liver biopsy can be useful to determine the etiology of acute liver failure, rule out infiltrative disease or malignancy, and identify contraindications to liver transplant.

The guidelines describe system-specific management of central nervous system manifestations of acute liver failure, coagulopathy, infection, and nutritional and metabolic support and make recommendations for the management of acute liver failure of various etiologies, including acetaminophen hepatotoxicity, other drug hepatotoxicity, and viral hepatitis.