Indirect: 0.2–0.7 mg/dL
Direct: <0.5 mg/dL
Clinical manifestations
No matter the exact cause of the patient’s liver failure, it inevitably affects the entire physiologic makeup. Physical examination is important for the approximation of liver and spleen size, evidence of bleeding abnormalities, identification of extravascular fluid shifts, and any other organ dysfunction. Listed in the table below are common clinical features of hepatic failure and their associated causes.
Clinical Features of Hepatic Failure and Associated Causes
Clinical Feature | Cause |
Anemia | Iron, vitamin B12, or folate deficiency; hypersplenism; bone marrow suppression |
Ascites | Portal hypertension; hypoalbuminemia; sodium and water retention |
Fetor hepaticus (pungent sour odor detected in exhaled breath) | Inability to metabolize methionine |
Gynecomastia | Increased circulating estrogen |
Hepatic encephalopathy (hepatic coma) | Inability to metabolize ammonia; increased cerebral sensitivity to toxins; hypoglycemia |
Hepatorenal syndrome | Decreased renal blood flow, particularly to the cortex; vasoconstriction; decreased glomerular filtration rate; renal retention of sodium |
Increased bleeding tendencies, nosebleeds, gingival bleeding, menstrual bleeding, easy bruising | Anemia; thrombocytopenia; decreased production of clotting factors; decreased adherence of circulating platelets |
Increased risk of infection | Endotracheal intubation with impaired cough reflex; intravenous catheters; central lines; urinary catheters; leukopenia; decreased neutrophil adherence; complement deficiencies |
Increased skin pigmentation | Increased activity of melanocyte-stimulating hormone |
Jaundice | Increased circulating bilirubin |
Leukopenia | Hypersplenism; bone marrow suppression |
Palmar erythema | Increased circulating estrogen |
Pectoral and axillary alopecia | Increased circulating estrogen |
Peripheral edema | Hypoalbuminemia; failure of the liver to inactivate aldosterone and antidiuretic hormone, with subsequent sodium and water retention |
Spider angiomas, “nevi” | Increased circulating estrogen |
Testicular atrophy | Increased circulating estrogen |
Thrombocytopenia | Hypersplenism; bone marrow suppression |
Weight loss and muscle wasting | Nausea and vomiting; anorexia; impaired gluconeogenesis; impaired insulin functioning; hypoproteinemia |