5. Alcoholic Liver Disease

Question 1

What is alcoholic liver disease?

Answer 1

The long-term excessive consumption of alcohol on the liver

Question 2

What may be the cause behind alcoholic liver disease having a variable onset and progression between people?

Answer 2

Genetic predisposition

Question 3

List the stepwise progression of ALD?

Answer 3

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

Question 4

What stage of ALD is alcoholic related fatty liver?

Can it be reversed, and how?

Answer 4

The first stage of ALD

If drinking stops, it can be reversed (takes around 2 weeks)

Question 5

What stage of ALD is alcoholic hepatitis?

What causes it?

Can it be reversed and if so how?

Answer 5

Second stage of ALD

Drinking over a long period or bing drinking

If mild can be reversed with permanent abstinence

Question 6

What stage of ALD is cirrhosis?

Describe the cirrhotic liver.

Can it be reversed?

Prognosis?

Answer 6

Last stage

Liver is made up of scar tissue rather than healthy, functioning tissue

Irreversible but abstinence will prevent further damage

Continued drinking has a very poor prognosis

Question 7

OH consumption limits?

Who should avoid completely?

Answer 7

No more than 14 units, spread evenly over 3 days at least and no more than 5 units in a day

If pregnant avoid compltetely

Question 8

OH consumption increases?

Answer 8

Risk of any cancer (especially mouth, throat and breast)

ALD (cirrhosis increases risk of hepatocellular carcinoma)

Pancreatitis

Alcoholic Cardiomyopathy

Wernicke-Korsakoff syndrome

Addiction

Question 9

How do you screen for harmful OH use?

Answer 9

CAGE screening tool:

Have you ever felt you should cut down?

Have you ever been annoyed by someone criticising your drinking?

Have you ever felt guilty about drinking?

Have you ever had an eye-opener in the morning to ease your hangover?

Or use the WHO’s AUDIT questionnaire: 10 questions and a score of 10 or + indicates harmful use

Question 10

List at least 7 signs of liver disease

Answer 10

Losing liver function:

1. Edema (no protein)
2. Bruising (no clotting factors)
3. Palmar erythema, gynaecosmastia, spider naevi (high estrogen, not metabolised)
4. Toxins (asterixis)
5. Jaundice and itch (bilirubin not metabolised)

Portal vein hypertension:

6. Ascites and caput medusa (portal hypertension causes fluid in peritoneal cavity and engorged epigastric veins)

Fatty, inflamed liver:

7. Hepatomegaly

Question 11

In ALD, what would the bloods show (spit into what happens to blood, liver and kidneys in ALD)?

Answer 11

Blood:
Elevated PT time
FCB shows macrocytosis aka raised MCV

Liver:
LFT show raised ALT, AST (ALP is raised later in the disease) raised bilirubin and reduced albumin

Kidneys:
UE deranged in hepato-renal syndrome

Question 12

Investigations for suspected ALD?

Answer 12

Bedside: obs and GI exam

Bloods: FBC, UE, TFT, LFT, CRP, ESR

Imaging: US, Fibroscan, CT, MRI

Procedure: endoscopy and liver biopsy

Question 13

General management of ALD

Answer 13

1. OH cessation (consider detoxication regime)
2. Nutritional support with vitamins (thiamine) and a high protein diet
3. Steroids improve short term outcomes (over 1 month) but infection and GI bleeding need to be managed first and do not improve outcomes
4. Treat complications of cirrhosis
5. Refer for liver transplant in severe disease, but must abstain from OH for 3m prior to referral

Question 14

Describe the range and timeframe of alcohol withdrawal syndromes

Answer 14

6-12h: H/A, tremor, sweating, anxiety, craving

12-24h: hallucinations

24-48h: seizures

24-72h: delirium tremens

Question 15

Why is delirium tremens a medical emergency?

Answer 15

35% mortality if left untreated

Question 16

What acute and chronic effects does OH have on the receptors of the brain?

What medical emergency is caused by the chronic effects of OH on the brain?

Answer 16

Acutely: stimulates GABA receptors which have a relaxing effect and inhibits glutamate receptors, inhibiting electrical activity, causing a relaxing effect

Chronic OH use causes the GABA system to be down-regulated and the glutamate system to be upregulated so the effects of OH are balanced

On abstinance the GABA under functions and glutamate over functions causing extreme excitability and adrenergic activity causing delirium tremens

Question 17

How is OH withdrawal managed?

Answer 17

Score the patient using CIWA-Ar tool

Chlordiazepoxide aka librium is used in medical treatment (titrated to required dose, on a reducing regimen for 5-7d)

Need IV high dose b-vitamins (pabrinex) and then oral b-vitamins (thiamine)

Question 18

Describe Wernicke-Korsakoff Syndrome

Answer 18

Thiamine (aka B-vitamin) deficiency

Thiamine is poorly absorbed in the prescence of OH, so alcoholics are B-vitamin deficient

Wernicke’s Encephalopathy (medical emergency, high mortality rate if untreated) occurs first: confusion, oculomotor disturbances (eye mvmt disturbance) and ataxia

Korsakoff’s Syndrome: retrograde and anterograde memory impairment and behavioural changes, often irreversible and pts require full time institutionalised care

Prevention and management: Thiamine supplementation and abstain from OH

Question 19

What is Fibroscan used to asses

Answer 19

Elasticity and degree of cirrhosis

Question 20

What indicated fatty changes on ultrasound of the liver?

Answer 20

Increased echogenicity

Question 21

What procedure is used to look for esophageal varices?

Answer 21

Endoscopy

Question 22

What 5 changes can CT and MRI visualise in a patient with ALD?

Answer 22

Fatty changes

Hepatocellular carcinoma

Hepatosplenomegaly

Blood vessel changes

Ascites

Question 23

How is the diagnosis of ALD confirmed?

Answer 23

Liver biopsy

Question 24

Before administrating steroids to a patient with ALD, what must be done?

Answer 24

Liver biopsy to confirm ALD

Question 25

SS of delirium tremens?

Answer 25

Extreme excitability and adrenergic activity:

Severe, sudden hypertension

Acute confusion

Severe agitation

Delusions

Hallucinations

Tremor
Tachycardia
Hyperthermia
Ataxia (difficult with co-ordinated mvmts)
Arrhythmia