Article Text

Download PDFPDF
Paracetamol induced hepatotoxicity
  1. S B K Mahadevan,
  2. P J McKiernan,
  3. P Davies,
  4. D A Kelly
  1. The Liver Unit, Birmingham Children’s Hospital, Birmingham, UK
  1. Correspondence to:
    Dr S B K Mahadevan
    The Liver Unit, Birmingham Children’s Hospital NHS Trust, Steelhouse Lane, Birmingham B4 6NH, UK; bkmsubra{at}


Aim: To identify the clinical and biochemical risk factors associated with outcome of paracetamol induced significant hepatotoxicity in children.

Methods: Retrospective case notes review of those with paracetamol overdose admitted from 1992 to 2002. Patients were analysed in two groups: group I recovered after conservative treatment and group II developed progressive liver dysfunction and were listed for liver transplantation.

Results: Of 51 patients (6 males, 45 females, aged 0.8–16.1 years), 6 (aged <7 years) received cumulative multiple doses, and 45 a single large overdose (median 345 mg/kg, range 91–645). The median (range) interval to hospital at presentation post-ingestion was 24 hours (4–65) and 44 hours (24–96) respectively in groups I and II. Patients received standard supportive treatment including N-acetylcysteine. All children in group I survived. In group II, 6/11 underwent orthotopic liver transplantation (OLT) and 2/6 survived; 5/11 died awaiting OLT. Cerebral oedema was the main cause of death. Children who presented late to hospital for treatment and those with progressive hepatotoxicity with prothrombin time >100 seconds, hypoglycaemia, serum creatinine >200 μmol/l, acidosis (pH <7.3), and who developed encephalopathy grade III, had a poor prognosis or died. Although hepatic transaminase levels were markedly raised in both groups, there was no correlation with necessity for liver transplantation or death.

Conclusion: Accidental or incidental paracetamol overdose in children may be associated with toxic liver damage leading to fulminant liver failure. Delayed presentation and/or delay in treatment, and hepatic encephalopathy ⩾grade III were significant risk factors, implying poor prognosis and need for OLT. Prompt identification of high risk patients, referral to a specialised unit for management, and consideration for liver transplantation is essential.

  • ALT, alanine transaminase
  • AST, aspartate transaminase
  • KCH, King’s College Hospital
  • OLT, orthotopic liver transplantation
  • PT, prothrombin time
  • paracetamol
  • fulminant liver failure
  • orthotopic liver transplantation
  • hepatotoxicity

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles

  • Précis
    BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health