A Sudden Crash in a Liver That Was Coping
Many of our patients live with cirrhosis for years. The disease moves slowly, and with the right treatment, the liver continues to function.
ACLF is different.
It’s a sudden collapse.
A person who was stable last week can become critically ill within a few days.
The liver stops working rapidly, and other organs start failing soon after.
This is why ACLF is much more dangerous than cirrhosis.
What ACLF Really Means?
Think of the liver as a hardworking factory.
In cirrhosis, that factory is damaged but still running.
In ACLF, something suddenly sets the factory on fire.
Medically, ACLF is a sudden and severe failure of the liver in someone who already has chronic liver disease, often leading to multi-organ failure if not treated immediately.
Why ACLF Happens:
Almost every ACLF case has two parts:
1. A liver that is already weakened
Due to:
- Alcohol
- Hepatitis B or C
- Fatty liver (NAFLD/NASH)
- Autoimmune issues
- Long-standing bile duct diseases
2. A sudden trigger
Such as:
- Heavy alcohol intake
- Severe infection
- Hepatitis A or E
- Bleeding in the stomach
- Herbal/Ayurvedic medicines
- Dehydration
- High blood sugar
- Major stress or surgery
When these two collide, the liver cannot cope, and ACLF develops.
ACLF vs. Cirrhosis: The Difference in Simple Words
| Cirrhosis | ACLF |
| Slow Disease | Sudden Crash |
| Mainly Liver Affected | Liver + Kidneys + Brain + Lungs |
| Body Adapts Slowly | Body Collapses Fast |
| Treatable With Medicines | Needs Urgent ICU care |
| Moderate Risk | Very high short-term risk |
| Cirrhosis gives you time | ACLF does not |
How ACLF Affects the Body: The Domino Effect We See in the ICU
1. Liver stops clearing toxins
Ammonia rises → brain gets affected → confusion → drowsiness → coma.
2. Kidneys fail
Blood flow drops → urine output falls → toxins increase further.
3. Lungs fill with fluid
Breathlessness, low oxygen, and sometimes a need for ventilator support.
4. Blood pressure crashes
The heart struggles to keep up.
5. Infections spread faster
The immune system becomes extremely weak.
This is why ACLF is a medical emergency.
Early Symptoms Families Should Never Ignore
ACLF often begins suddenly.
If a person has cirrhosis and experiences any of the following, come to the hospital immediately:
- Sudden yellowing of eyes
- Fever
- Confusion, irritability
- Drowsiness
- Reduced urine
- Vomiting blood
- Breathlessness
- Abdominal swelling is increasing quickly
- Severe weakness
- Loss of appetite
A delay of even a few hours can change the outcome.
Why ACLF Is More Dangerous Than Cirrhosis
1. The body cannot adjust
The damage is too fast and too severe.
2. Multiple organs fail at the same time
Not just the liver — kidneys, brain, lungs, and heart get affected.
3. Infections become life-threatening
Even mild infections can turn severe in 24–48 hours.
4. High risk of internal bleeding
Because the liver stops making clotting factors.
5. Very high short-term mortality
This is the hardest part to explain to families.
Without urgent treatment:
- Many patients deteriorate within a week
- Survival drops sharply in 28 days
This seriousness is why I always encourage rapid evaluation.
How I Diagnose ACLF: Clear, Structured Steps
When a patient comes with suspected ACLF, the evaluation begins immediately:
Blood Tests
To check:
- Liver function
- Kidney function
- Infections
- Ammonia
- Clotting
- Electrolytes
Ultrasound / CT
To look for infection, fluid, blockages, or bleeding.
Cultures
Blood, urine, and abdominal fluid to identify infection early.
ACLF Scoring
Tools like CLIF-SOFA, AARC, and MELD-Na help us understand severity and guide decisions.
Treatment of ACLF: Why Every Hour Matters
ACLF needs a specialised liver ICU and a team skilled in handling multi-organ failure.
1. Stabilising the patient
This includes oxygen, ventilator support, blood pressure support, and dialysis if needed.
2. Treating the trigger
For example:
- Strong antibiotics for infection
- Stopping alcohol
- Correcting bleeding
- Treating hepatitis
- Hydration and electrolytes
3. Supporting the liver
Using:
- Albumin
- Lactulose and rifaximin
- Plasma/platelets
- Vitamin K
- Nutrition
4. Managing complications
Infections, bleeding, kidney failure, brain swelling — each needs careful monitoring.
5. Early consideration for liver transplant
Whenever I see signs that recovery is unlikely without transplant, I discuss it with the family immediately.
Waiting too long reduces survival.
Can ACLF Recover Without a Transplant?
Yes, some patients recover, especially when:
- The trigger is treatable
- Diagnosis is early
- There is no multi-organ failure
- ACLF is Grade 1
But once ACLF reaches Grade 2 or Grade 3, survival without transplant decreases sharply.
This is why early decision-making is essential.
Who Is at Highest Risk?
People with:
- Alcohol-related liver disease
- Hepatitis B
- Frequent infections
- Poorly controlled diabetes
- Repeated fluid build-up
- Use of untested herbal medicines
For them, even a small fever or stomach infection needs attention.
How You Can Prevent ACLF
1. Avoid alcohol completely
Not “less alcohol” — zero alcohol.
2. Get vaccinated
Hepatitis A and B vaccines prevent major triggers.
3. Avoid herbal and alternative medicines
Many cause silent liver injury.
4. Treat infections early
Never ignore fever, cough, or a urinary infection in someone with liver disease.
5. Attend regular follow-ups
Every 1–3 months, depending on severity.
6. Maintain good nutrition
Protein restriction is outdated — the right diet strengthens the body.
What Families Should Do in an Emergency
If a cirrhosis patient suddenly:
- Seems confused
- Stops passing urine
- Develops fever
- Vomits blood
- Becomes breathless
Come to a liver care centre immediately.
Do not wait for symptoms to “settle on their own.”
ACLF worsens hour by hour.
Our Message to Patients and Families
ACLF is frightening because it comes suddenly.
Families often feel shocked, guilty, or helpless.
But remember:
- It is not your fault.
- It is not caused by one mistake.
- Most cases are due to infections or triggers that are hard to predict.
What matters most is early action.
With timely treatment, structured ICU care, and correct decision-making, many patients recover and return to normal life.
Awareness and speed save lives.
Conclusion
ACLF is one of the most serious emergencies in liver disease.
But it is also one of the few where timing can completely change the outcome.
If you or your loved one has cirrhosis, remember these three things:
- Know the early signs
- Avoid known triggers
- Reach the hospital at the first hint of deterioration
The faster we act, the better the results.