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Many patients with liver disease may not discover it until it is too late. Know the signs and symptoms of liver failure so you can seek help early.

Last updated on 18 November 2020

The liver: A vital organ

Liver failure
The liver is an important organ situated in the upper part of the abdomen. It has several functions.

It is responsible for manufacturing many proteins required for the normal functioning of the body, such as proteins which enable our blood to clot when we have a cut. It manufactures bile which is important in fat digestion. The liver also helps to process and eliminate waste products and toxins from the blood stream and the body.

It is an important organ for the breakdown of chemicals including the medicines we consume. It also helps in the breakdown of red blood cells converting the haemoglobin in the red blood cells into bilirubin and which is then excreted through the bile.

Liver failure

Liver failure happens when large parts of the liver become damaged beyond repair and the liver can’t work anymore. It is a life-threatening condition that requires urgent medical care.

A failed liver is usually the final stage of many liver diseases and happens gradually, over many years. This is known as chronic liver failure. In rare cases, acute liver failure happens where the liver suddenly stops working due to causes such as ingestion of certain toxins or drugs or a viral infection.

Early symptoms include nausea, loss of appetite, fatigue, and diarrhoea. As liver failure progresses, other symptoms such as jaundice, bleeding tendency, swollen abdomen, mental confusion, and sleepiness are observed.

Liver cirrhosis is one of the most common conditions that leads to chronic liver failure. It is a condition where scar tissue gradually replace healthy liver cells leading to a damaged liver. Heavy drinking and obesity are risk factors for cirrhosis.

Signs and symptoms of liver failure

Despite the liver’s importance, patients with liver disease often do not have signs or symptoms. This is because the liver has excess functional capacity. Signs and symptoms of impaired liver function will manifest only when the liver function is reduced by more than half. These may include:

  • Jaundice (yellowing of the whites of the eyes and skin)
  • Abdominal and leg swelling
  • Drowsiness
  • Easy bruising
  • Abdominal discomfort
  • Nausea
  • Disorientation

Liver function blood tests

Very often, one discovers that the liver is not quite normal when abnormalities in the liver tests are found. While abnormalities in these tests usually mean that something is happening in the liver, none of these tests are specific for the liver and diseases outside the liver may cause changes in these tests.

Consult a gastroenterology specialist and get the appropriate tests done to understand better what is going on in your liver.

Protein and albumin levels

The protein and albumin levels reflect the ability of the liver to make proteins. A reduction in protein and albumin occurs as the liver function deteriorates and the liver is no longer able to manufacture proteins. However, protein and albumin levels may also occur in patients with severe infections or if proteins are lost in the urine or stools.

Bilirubin level

The bilirubin level reflects the liver’s ability to eliminate waste products from the body. However, high bilirubin levels may also reflect a blood disorder which causes increased breakdown of red blood cells and increased bilirubin production.

Alanine transaminase (ALT) and aspartate transaminase (AST)

The alanine transaminase and aspartate transaminase (AST) are proteins found inside liver cells. Increased levels could mean the presence of a liver disease which damages liver cells causing the release of these proteins into the bloodstream. However, AST is also found in muscles cells and may be high in patients with damage to skeletal or cardiac muscle damage.

Alkaline phosphatase

Alkaline phosphatase is an enzyme which is found in the liver and the bile ducts. Increased alkaline phosphatase often reflects the presence of either liver or bile duct disease. However, this is a protein which is also found in the bone and the intestines. Fractures and diseases affecting the bone also cause increased levels of alkaline phosphatase.

Gamma glutamyl transferase

The gamma glutamyl transferase (GGT) is an enzyme which is found in the liver and is elevated in liver diseases. It is often used in conjunction with the alkaline phosphatase to determine that an elevated alkaline phosphatase level is caused by liver disease. However, the GGT is also elevated in diseases of the bile duct and the pancreas.


The other signs and symptoms of liver disease occur only when the liver starts to fail and is unable to carry out its function. This often occurs only late in the course of disease. The most famous sign of liver disease is jaundice, where the white of the eyes and the skin turn yellow. This is caused by an accumulation of bilirubin in the body because the liver can no longer eliminate it as it begins to fail.

Jaundice may be acute and temporary, as in the case of acute hepatitis A infection, where the liver damage is transient and the jaundice will reverse once the liver recovers. However, in patients with chronic liver disease where there is ongoing and continuing damage, such as hepatitis B and alcohol induced liver disease, the jaundice may persist for a longer period of time.

Abdominal and leg swelling

A patient whose liver fails will accumulate fluid in the abdomen and in the legs. The leg swelling often starts in the feet and more of the legs will become affected when the function of the liver worsens and fluid accumulation increases. Abdominal swelling is often not obvious initially. However, as it becomes worse, the patient’s abdomen will become more prominent and the umbilicus may also start turning outwards.


The liver plays an important role in removing chemicals and toxins from the bloodstream. These may be produced by the bacteria in our gut which is then absorbed into the bloodstream, or they may be produced when the body breaks down cells and proteins. As the liver function deteriorates, the liver is unable to remove toxins from the bloodstream quickly enough. High concentrations of toxins like ammonia can affect the brain which will cause drowsiness. This is known as hepatic encephalopathy.

Easy bruising

The liver manufactures some of the proteins important for blood clotting. In patients with chronic liver disease whose liver function is deteriorating, the liver’s ability to make these blood clotting proteins is also reduced. Patients will then bleed more easily resulting in bruises forming with even minor trauma.

Abdominal discomfort

Abdominal discomfort is an uncommon symptom in patients with liver disease. The liver tissue itself does not have any nerve endings and so very often no pain or discomfort is experienced. However, nerve endings are found in the capsule surrounding the liver and when the liver swells up very quickly, stretching of this capsule may result in discomfort or pain in the upper abdomen. An example of this would be the swelling of the liver in patients with acute hepatitis A.

None of the blood test abnormalities, symptoms or signs are specific for liver disease. Should one have any suspicion that the liver is abnormal, the family doctor should be consulted and appropriate tests done. Appropriate referrals can then be made should these suspicions be true.

Causes of chronic liver disease

The most common causes of chronic liver disease include:

  • Hepatitis B
  • Hepatitis C
  • Heavy alcohol consumption
  • Non-alcoholic fatty liver disease

Other causes, which are less commonly seen are:

  • Paracetamol overdose, which can damage the liver or lead to failure
  • Reactions to certain prescription or herbal medications
  • Eating poisonous wild mushrooms called Amanita phalloides
  • Industrial toxins including carbon tetrachloride, a cleaner and degreaser
  • Hemochromatosis is an inherited disorder that causes iron build up in the liver


Article reviewed by Dr Ling Khoon Lin, gastroenterologist at Mount Elizabeth Hospital


What is Liver Failure? (n.d) Retrieved October 27, 2020, from https://www.webmd.com/digestive-disorders/digestive-diseases-liver-failure#1

Cirrhosis and Your Liver (n.d) Retrieved October 27, 2020, from https://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information#1

Ling Khoon Lin
Mount Elizabeth Hospital

Dr Ling Khoon Lin is a gastroenterologist practising in Mount Elizabeth Hospital, Singapore.