2+ Alcoholic Liver Disease

Question 1

What is alcoholic liver disease?

Answer 1

A range of progressive liver conditions caused by chronic and excessive alcohol consumption

Question 2

How is alcoholic liver disease classified?

Answer 2

1. Alcoholic steatosis (Fatty Liver)
2. Alcoholic Hepatitis (inflammation + necrosis)
3. Alcoholic Cirrhosis

Question 3

Who is more likely to get alcoholic liver disease?

Answer 3

Middle aged + older adults
Greater risk in F

Question 4

What causes alcoholic liver disease?

Answer 4

Chronic alcohol use!

Obesity, smoking, co-existence of Hep C increase the risk

Question 5

What is the pathophysiology of Alcoholic Liver disease?

Answer 5

• Alcohol dehydrogenase (hepatic enzyme) and acetaldehyde dehydrogenase (mitochondrial enzyme) reduce NAD to NADH –> excessive NADH = inhibited gluconeogenesis and increased FA oxidation –> steatohepatitis
• Cytochrome p450 pathway generates free radicals by oxidation of NADPH to NADP
• Chronic use activates a 3rd metabolism site: hepatic MAC –> produce TNF and induce the production of reactive oxygen species

Question 6

How does alcoholic fatty liver present?

Answer 6

Mostly asymptomatic
Can have hepatomegaly

Question 7

How does alcoholic hepatitis present?

Answer 7

• RUQ abdominal pain
• Hepatomegaly
• N/V, anorexia, weight loss
• Jaundice in severe
• Splenomegaly
• Ascites
• Caput medusae
• Haematemesis + melaena
• Palmar erythema
• Spider naevi
• Asterixis
• Dupuytren’s contracture
• Gynaecomastia

Question 8

How does alcoholic cirrhosis present?

Answer 8

• Fatigue, malaise, weight loss
• Jaundice
• Pruritus
• Skin changes: dry and atrophic
• Amenorrhea

Signs of chronic liver disease:
- Dupuytren’s, asterixis, palmar erythema, leukonychia
- Fetor hepaticus
- Spider naevi, gynaecomastia, loss of hair
- Peripheral oedema
- Caput medusae
- Hepatosplenomegaly
- Ascites

Question 9

What laboratory Ix do you do when you suspect alcoholic liver disease?

Answer 9

LFTs:
- AST + ALT elevated, AST: ALT >2
- Increased GGT (alcohol induces enzyme activation)
- Impaired synthetic function: low albumin
- Impaired metabolic function: bilirubin elevated

Liver screen to rule out the other causes:
- Viral hepatitis serology
- Serum iron, ferritin, transferrin = haemochromatosis
- Urine copper + serum ceruloplasmin = Wilson’s
- AMA: PBC
- ANA and ASMA: Autoimmune hepatitis
- Serum alpha1 antitrypsin level: alpha 1 antitrypsin deficiency

FBC
- Anaemia
- Leucocytosis
- Thrombocytopenia

UEC:
- Often hyponatremic, hypokalaemic, hypomagnesemia
- Urea + creatinine elevated in hepatorenal syndrome

Coags:
- Prolonged PT/INR (reduced synthetic function of liver)

Serum ammonia if concerned about hepatic encephalopathy?

Question 10

What’s included in a liver screen?

Answer 10

Obvi LFTs

• Viral hepatitis serology
• Serum iron, ferritin, transferrin = haemochromatosis
• Urine copper + serum ceruloplasmin = Wilson’s
• AMA: PBC
• ANA and ASMA: Autoimmune hepatitis
• Serum alpha1 antitrypsin level: alpha 1 antitrypsin deficiency
• Thrombophilia screen + JAK2 mutation screen = Budd-Chiari

Question 11

What imaging do you do for suspected alcoholic liver disease?

Answer 11

Hepatic USS:
- Hepatomegaly
- Fatty liver
- Cirrhosis
- Evidence of portal HTN
- Transient elastography to check for hepatic fibrosis
- Check the hepatic and/or caval veins for thrombosis or stenosis

Question 12

When do you do a liver biopsy?

Answer 12

When you suspect AI hepatitis

Question 13

What is the DDx for suspected alcoholic liver disease?

Answer 13

MAFLD
Viral Hepatitis
Acute Liver Failure
AI Hepatitis
Haemochromatosis
Alpha 1 antitrypsin deficiency
Wilson’s disease

Question 14

How do you manage alcoholic liver disease?

Answer 14

1. Cessation of alcohol/alcohol withdrawal management
   (diazepam)
2. Weight reduction + smoking cessation
3. Nutritional supplementation/vitamins
   a. Always give thiamine!!
4. Patients with a Maddrey’s discriminant function (MDF) [based on
   PTT and BR] over 32 or hepatic encephalopathy –>
   corticosteroids
5. If bad ascites = Frusemide or spironolactone
   a. Refractory to salt restriction and diuretics –> large volume
   paracentesis or transjugular intrahepatic portosystemic
   shunt (TIPS) therapy
6. Liver transplant if end stage

Question 15

What are the complications of alcoholic liver disease?

Answer 15

• Hepatic encephalopathy
• Portal hypertension
• GIT bleeding
• Coagulopathy
• Renal failure
• Hepatorenal syndrome
• HCC
• Other organ involvement from alcohol use: pancreatitis, gastritis,
  Wernicke-Korsakoff