3. Alcoholic Liver Disease (inc hepatitis & cirrhosis briefly)

Question 1

What actually is one unit of alcohol and how long does it take for the body to process one unit

Answer 1

1 unit = 10ml or 8g of pure alcohol and it takes around 1 hour to process

Question 2

What are the recommendations on alcohol consumption and what does the term 13% ABV mean

Answer 2

limit is 14 units a week best spread over 3 or more days

13 ABV means 13% pure alcohol by volume

Question 3

Heavy drinkers who suddenly stop drinking usually suffer from what medical term

Answer 3

delirium tremens

Question 4

What is delirium tremens and why is it so dangerous

Answer 4

acute confusional state which left untreated results in seizures and even death

Question 5

Under what circumstances should a heavy drinker be admitted to hospital

Answer 5

if they are having acute alcohol withdrawal plus a high risk of developing alcohol withdrawal seizures or delirium tremens

Question 6

what is the treatment options for acute alcohol withdrawal and delirium tremens

Answer 6

acute alcohol withdrawal - consider benzodiazepines such as librium or carbamazepine ( can offer clomethiazole but with caution)
management of delirium tremens should be with oral lorazepam (if they decline offer parenteral or haloperidol)

Question 7

There is a progression of alcoholic liver disease;

1. Alcohol related fatty liver
2. Alcoholic hepatitis
3. Cirrhosis

Q: why does alcohol related fatty liver occur

Answer 7

Drinking leads to a build-up of fat in the liver. If drinking stops this process reverses in around 2 weeks.

Question 8

There is a progression of alcoholic liver disease;

1. Alcohol related fatty liver
2. Alcoholic hepatitis
3. Cirrhosis

Q: why does alcohol lead to alcoholic hepatitis

Answer 8

Drinking alcohol over a long period causes inflammation in the liver sites.
Binge drinking is associated with the same effect.
Mild alcoholic hepatitis is usually reversible with permanent abstinence

Question 9

There is a progression of alcoholic liver disease;

1. Alcohol related fatty liver
2. Alcoholic hepatitis
3. Cirrhosis

Q: what is cirrhosis in relation to drinking

Answer 9

where the liver is made up of scar tissue rather than healthy liver tissue

this is irreversible

stopping drinking can prevent further damage

Question 10

The CAGE questionnaire is used in clinical practice to screen for harmful alcohol use, what does CAGE stand for

Answer 10

C – CUT DOWN? Ever thought you should?

A – ANNOYED? Do you get annoyed at others commenting on your drinking?

G – GUILTY? Ever feel guilty about drinking?

E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?

Question 11

What are the most common complications of alcohol

Answer 11

Alcoholic Liver Disease
Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma
Alcohol Dependence and Withdrawal
Wernicke-Korsakoff Syndrome (WKS) - caused by lack of vitamin B (ie thiamine)
Pancreatitis
Alcoholic Cardiomyopathy

Question 12

Name some signs of Liver disease

Answer 12

Jaundice
Hepatomegaly
Spider Naevi- across the body 
Palmar Erythema - reddening of the hands
Gynaecomastia
Bruising – due to abnormal clotting
Ascites- fluid build up 
Caput Medusae – engorged superficial epigastric veins
Asterixis – “flapping tremor” in decompensated liver disease

Question 13

What is the general management of excessive alcohol drinking

Answer 13

• Stop drinking alcohol permanently
• Consider a detoxication regime
• Nutritional support with vitamins (particularly thiamine) and a high protein diet
• Steroids improve short term outcomes (over 1 month) in severe alcoholic hepatitis but infection and GI bleeding need to be treated first and do not improve outcomes over the long term
• Treat complications of cirrhosis (portal hypertension, varices, ascites and hepatic encephalopathy)
• Referral for liver transplant in severe disease however they must abstain from alcohol for 3 months prior to referral

Question 14

Alcohol withdrawal; what signs and symptoms occur at the following time intervals when someone who is alcohol dependant stops drinking;
6-12 hours
12-24 hours
24-48 hours
24-72 hours

Answer 14

6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delerium tremens”

Question 15

Delirium tremens is a medical emergency as alcohol stimulates GABA receptors and down-regulated glutamate receptors which means in chronic alcohol use this imbalance doesn’t level out. What does this present as

Answer 15

Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias

Question 16

How can you manage/treat alcohol withdrawal

Answer 16

the CIWA-Ar (clinical institute withdrawal assessment) tool to score the patient and guide treatment

chlordiaepoxide (librium) which is a benzodiazepine for 5-7 days

IV high dose B vitamins (pabrinex) which should be followed by regular lower dose oral thiamine

Question 17

Alcohol excess leads to what vitamin deficiency and in extreme cases what condition does this deficiency cause

Answer 17

thiamine aka vitamin B1

can lead to wernickes encephalopathy

Question 18

Thinking about differentials to abdo pain:

If the patient has enlarged liver what does it suggest

Answer 18

Its a sign of liver disease

Question 19

Thinking about differentials to abdo pain:

the absence of what clinical features make it less likely that the patient has underlying chronic liver disease or cirrhosis

Answer 19

Absence of things like spider naevi, palmar erythema, portal hypertension, leukonychia, caput medusa (engorged veins around the umbilicus)

Question 20

Thinking about differentials to abdo pain:

in the absence of signs of chronic liver disease or cirrhosis what does jaundice + abdo pain lead to you thinking someone may have

Answer 20

acute liver failure or hepatitis

Question 21

Thinking about differentials to abdo pain:

if the patient doesn’t have a temperature aka isn’t febrile, what is the abdo pain less likely to be caused by

Answer 21

an infection eg viral hepatitis

or the underlying cause is complicated by an infection

Question 22

Thinking about differentials to jaundice and abdo pain:

If the blood results showed that the rise in ALT/AST is greater than the rise in alkaline phosphatase what does it lead you to think the cause of the jaundice is

a) hepatoceullar damage
b) obstructive cause

Answer 22

hepatoceullar damage

Question 23

Thinking about differentials to jaundice and abdo pain:

If the blood results showed that the rise in alkaline phosphatase is greater than the rise in ALT/AST what does it lead you to think the cause of the jaundice is

a) hepatoceullar damage
b) obstructive cause

Answer 23

obstructive cause

Question 24

Define Hepatitis

Answer 24

This means liver inflammation ( and not necessarily infection)

Question 25

what is the difference between acute Vs chronic hepatitis

Answer 25

inflammation persisting for more than 6 months and this is generally useful for viral hepatitis

Question 26

define cirrhosis

Answer 26

Fibrosis of the liver with nodule formation

Question 27

What are the common signs for someone who has acute hepatitis and then what can they have in severe cases

Answer 27

generally unwell
jaundice
RUQ pain (due to the liver swelling)

in severe cases
confusion (due to bilirubin encephalopathy)
coagulopathy (not making enough clotting factors) so get bruising

Question 28

what are the symptoms of chronic hepatitis

Answer 28

often are asymptomatic but may have fatigue
chronic hepatitis is typically only discovered during other routine things
(may actually present with cirrhosis or could have just been picked up during screening programmes)

Question 29

What does fulminant hepatitis mean

Answer 29

acute hepatitis with liver failure

Question 30

How is fulminant hepatitis defined

Answer 30

defined as developing encephalopathy within 28 days of jaundice
poor prognosis and often needs transplantation
note that it must be acute hepatitis and not due to anything else

Question 31

Cirrhosis causes what two main problems in relation to the liver

Answer 31

loss of function

portal hypertension

Question 32

in someone with cirrhosis cause by loss of function of the liver, what signs are seen

Answer 32

o Jaundice
o Coagulopathy (unable to form the clotting factors)
o Decreased drug metabolism (sedatives and opiates be careful with)
o Decreased hormone metabolism (increased levels of oestrogen therefore present with gynaecomastia, spider naevi and palmar erythema as well as loss of secondary body hair)
o Increased sepsis

Question 33

If someone with cirrhosis caused by portal hypertension, what signs are seen

Answer 33

o	Varices (enlarged veins, could be oesophageal or around the umbilicus) 
o	Piles 
o	Ascites (water retention in the abdo due to the RAAS axis making the kidneys  
o	Hepatic Encephalopathy (as blood is passing through this varices, there is a build-up of toxins)
o	Renal failure (renal artery constriction)

Question 34

Name some causes of cirrhosis

Answer 34

•	Hazardous alcohol 
•	Chronic hepatitis B + C 
•	Autoimmune liver disease 
•	Inherited diseases such as 
o	Hemochromatosis 
o	Wilsons disease 
•	Chronic obstruction

Question 35

name some clinical signs of cirrhosis on physical examination

Answer 35

• Spider naevi (due to increase in oestrogen)
• Palmar erythema (red palms due to increase in oestrogen)
• Leukonychia (white spots on the nails)
• Caput medusa (engorged veins around the umbilicus)

Question 36

What are the 4 most common causes of liver cirrhosis

Answer 36

Alcoholic liver disease
non-alcoholic fatty liver disease
Hep B
Hep C

Question 37

In cirrhosis what may an ultrasound show

Answer 37

• Nodularity of the surface of the liver
• a “corkscrew” appearance to the arteries with increased flow as they compensate for reduced portal flow
• enlarged portal vein with reduced flow
• ascites
• splenomegaly

Question 38

What is non-alcoholic fatty liver disease (NAFLD) characterised by

Answer 38

fat deposits in the liver cells

Question 39

What are the stages of liver disease leading to cirrhosis

Answer 39

Non-alcoholic Fatty Liver Disease
Non-Alcoholic Steatohepatitis (NASH)
Fibrosis
Cirrhosis

Question 40

What are the risk factors for non-alcoholic fatty liver disease (NAFLD)

Answer 40

Obesity
Poor diet and low activity levels
Type 2 diabetes
High cholesterol
Middle age onwards
Smoking
High blood pressure