The clinical manifestations of hepatic failure from chronic liver disease are much the

same regardless of the cause of the disease. Jaundice is an almost invariable

finding. Impaired hepatic synthesis and secretion of albumin lead to
hypoalbuminemia, which predisposes to peripheral edema. Hyperammonemia is
attributable to defective hepatic urea cycle function. Signs and symptoms of chronic
disease include palmar erythema (a reflection of local vasodilatation) and spider
angiomas of the skin. Each angioma is a central, pulsating, dilated arteriole from
which small vessels radiate. There may also be impaired estrogen metabolism and
consequent hyperestrogenemia, which leads to hypogonadism and gynecomastia in
men. Acute liver failure may manifest as jaundice or encephalopathy, but notably
absent on physical examination are the other stigmata of chronic liver disease.
Hepatic failure is life-threatening for several reasons. The accumulation of toxic
metabolites may have Clinical Syndromes 605 deconjugated by gut bacterial -
glucuronidases and degraded to colorless urobilinogens. The urobilinogens and the
residue of intact pigment are largely excreted in feces. Approximately 20% of the
urobilinogens are reabsorbed in the ileum and colon, returned to the liver, and
promptly reexcreted into bile. Conjugated and unconjugated bile acids also are
reabsorbed in the ileum and returned to the liver by the enterohepatic circulation.
widespread effects and patients are highly susceptible to failure of multiple organ
systems. Thus, respiratory failure with pneumonia and sepsis can give rise to renal
failure and thus claim the lives of many individuals with hepatic failure. A
coagulopathy develops, attributable to impaired hepatic synthesis of blood clotting
factors. The resultant bleeding tendency may lead to massive gastrointestinal
hemorrhage as well as bleeding elsewhere. Intestinal absorption of blood places a
metabolic load on the liver that worsens the severity of hepatic failure. The outlook
with full-blown hepatic failure is particularly grave for persons with chronic liver
disease. A rapid downhill course is usual, with death occurring within weeks to a few
months in about 80% of cases. About 40% of patients with acute liver failure may
recover spontaneously. Liver transplantation in acute or chronic liver failure can be
curative, however.