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Clin Med III Unit 2 > 5 Alcoholic Liver Disease and Liver Cancer > Flashcards

5 Alcoholic Liver Disease and Liver Cancer Flashcards

1
Q

Damage to your liver function due to alcohol abuse

A

Alcoholic Liver Disease (ALD)

Occurs in about 25-30% of heavy drinkers

Gene mutations have been linked to the risk of alcoholic liver disease

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2
Q

____% of all deaths from liver disease are attributed to alcohol

A

45%

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3
Q

ALD has replaced HCV as the leading cause of …

A

Liver transplantation in the USA

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4
Q

What are the three main patterns of injury in ALD?

A

Fatty liver (Simple Steatosis

Alcoholic Hepatitis

Chronic Hepatitis with fibrosis or cirrhosis

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5
Q

The risk of developing cirrhosis increases with daily consumption of _____ for men and _______ for women

A

Men: >3 drinks per day > 5 years

Women >2 drinks per day > 5 years

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6
Q

_____ are more sensitive to alcohol

A

Women

Twice as sensitive to EtOH hepatotoxicity
Develop more severe ALD at lower doses with shorter duration

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7
Q

What is the incidence of ALD like between ethnic groups?

A

African Americans>Hispanic>Caucasian males

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8
Q

____ and _____ act together to increase risk of liver disease

A

Obesity and excess body weight

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9
Q

______ and alcohol is associated with a more rapid progression of liver disease

A

Hep C

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10
Q

ALD and smoking is associated with ….

A

Increased risk of hepatocellular cancer

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11
Q

Risk factors for ALD

A

Amount of alcohol ingested**

Type of alcohol may influence risk
• Beer or spirits > wine

Pattern of drinking
• Outside of meal times increases risk 2.7 times

Relationship of quantity and ALD is not completely linear

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12
Q

Accumulation of fat (small or large droplets) in the cytoplasm of the liver cells

A

Fatty liver or hepatic steatosis

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13
Q

Simple uncomplicated fatty liver is usually …

A

Asymptomatic and self-limited

Clinical findings minimal to absent but hepatomegaly may be detectable

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14
Q

Fatty liver may ____________ with abstinence after about 4-6 weeks

A

Be completely reversible

Some studies show 5-15% progression to fibrosis or cirrhosis despite abstinence though

Continued alcohol use increases the risk of progression to cirrhosis

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15
Q

Inflammation of the liver characterized by necrosis and fibrotic scaring in the setting of history of chronic or current heavy alcoholic consumption

A

Alcoholic hepatitis

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16
Q

Clinical features of alcoholic hepatitis

A

Spectrum is asymptomatic to mild to severe

In severe cases, may see:
Fever
Leukocytosis
Hepatic encephalopathy***** (b/c inability to clear ammonia)
Spider angiomas***
Jaundice
Hepatosplenomegaly with liver tenderness
Edema (scrotal or LE)
Ascites
Variceal bleeding
Oliguria
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17
Q

Lab findings for alcoholic hepatitis

A 
Leukocytosis w/ left shift
Macrocytosis 
Thrombocytopenia
AST/ALT ratio >2********* with AST 2-6x ULN
ALP mildly elevated
Bilirubin elevated
PT/INR elevated
Low albumin
Hyponatremia, hypokalemia
GTP elevated
Low Folate
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18
Q

What are some histologic findings for alcoholic hepatitis?

A

Fatty infiltration

Neutrophil infiltration around clusters of necrotic hepatocytes

Clumps of intracellular material (Mallory bodies)***

Fibrosis around hepatic venules (precursor to cirrhosis)

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19
Q

How is ALD diagnosed?

A

Liver biopsy is only required for Dx of alcoholic hepatitis when there is an unclear history of alcohol use and elevated LFTs

Confounded by other risk factors for liver disease and considering pharmacotherapy

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20
Q

Failure of the liver to detoxify noxious agents of gut origin b/c of hepatocellular dysfunction and portosystemic shunting —> impaired brain function with advanced liver disease

A

Hepatic encephalopathy

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21
Q

_____ is the best known neurotoxin that precipitates hepatic encephalopathy

A

Ammonia

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22
Q

How do you manage hepatic encephalopathy?

A

Treat any precipitating factors: GI bleed, infection, sedating meds, electrolyte abnormalities, constipation, renal failure

Don’t use benzos or opioids if possible

Lactulose for acute over HE and secondary prophylactic therapy for an indefinite period

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23
Q

What are the clinical signs of hepatic encephalopathy?

A

EEG changes and flapping tremor (asterxisis)

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24
Q

What grade of hepatic encephalopathy:

Changes in behavior, mild confusion, slurred speech, disordered sleep pattern

A

Grade I (Subclinical or covert encephalopathy)

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25
What grade of hepatic encephalopathy: Lethargy, moderate confusion, +/- asterixsis
Grade II
26
What grade of hepatic encephalopathy: Marked confusion (stupor), incoherent speech, sleeping but can be aroused
Grade II
27
What grade of hepatic encephalopathy: Coma, unresponsive to pain
Grade IV
28
Brief cognitive screening tools which do not require psychological expertise in administration and interpretation, used to evaluate psychomotor speed and cognitive flexibility
Strop Test Able to diagnose minimal hepatic encephalopathy with excellent sensitivity/specificity
29
Which patients with alcoholic hepatitis require hospitalization?
Those with high mortality rate based on risk assessment calculators: • Model of End Stage Liver Disease (MELD) score > 20 • Maddery (Modified) Discriminant Factor (MDF) ≥ 32 • Lillie Score (labs over time) used to determine if steroids should be continued
30
What is essential to the management of alcoholic hepatitis?
D/C ALL ALCOHOL and maintain complete abstinence
31
How do you manage mild-sever alcoholic hepatitis?
Treatment of alcohol withdraw and infection surveillance Fluid overload management (diuretics) Meds for HE (Lactulose, Rifaximin) ``` Severe disease (MDF ≥32 or MELD >20) consider steroid tx and d/c if not effective on day 7 using Lillie score +/- liver transplant ``` Nutritional assessment and therapy Do not limit protein intake Sodium restriction (<2000 mg per day) Address vitamin deficiencies/malnutrition
32
What med do you need to d/c in patients with alcoholic hepatitis?
Non-selective beta blockers, as they are associated with increased risk of AKI
33
Widespread destruction and regeneration of liver tissue with marked increase in fibrotic connective tissue, nodules, and permanent alterations in the structure of the organ
Cirrhosis Scarring and increased connective tissue —> impairment of liver function
34
Cirrhosis is considered compensated if...
Portal pressure <10
35
Median survival with compensated cirrhosis
~12 years
36
Clinical manifestations of compensated cirrhosis
Splenomegaly (thrombocytopenia, leukopenia, anemia, AST elevation)
37
Decompensated cirrhosis is characterized by ...
Increased portal pressure (>10) and decreased liver function Median survival <2 years
38
Clinical manifestations of decompensated cirrhosis
``` Ascites Esophageal and rectal varicose Splenomegaly (leukopenia, thrombocytopenia) Dilated abdominal veins Encephalopathy Jaundice ```
39
Increased pressure within the portal venous system
Portal HTN
40
What are the three possible sites of obstruction to flow that can lead to portal hypertension?
Prehepatic - portal vein thrombosis Intrahepatic - cirrhosis**** Posthepatic - CHF, constrictive pericarditis
41
Clinical manifestations of portal HTN
Caput medusae Varies Ascites
42
Lab findings for alcoholic cirrhosis
Similar to alcoholic hepatitis AST elevation or can be normal in compensated Anemia of chronic disease, from folate deficiency, suppression of hematopoiesis, hemolysis, GI blood loss, or Splenomegaly Thrombocytopenia Coagulation abnormalities (reduced synthesis of clotting factors) Thrombocytopenia, leukopenia
43
Treatment for cirrhosis
Treat/prevent complications of portal HTN and cirrhosis Variceal surveillance (EGD) +/- banding HCC surveillance (AFP q6 months) Non-selective beta blocker prophylaxis for prevention of variceal bleeding - HR 55-60 and SBP <90 is the goal
44
How do you treat ascites associated with cirrhosis?
Adherence to less than 2g/d sodium Diuretics (Lasix, spironolactone) Fluid restriction ONLY if sodium is <125 For Refractory ascites: • Stop Beta Blocker • Therapeutic paracentesis (with albumin if >5-6 L drained) • TIPS (transjugular intrahepatic portosystemic shunt)
45
During therapeutic paracentesis, _______ is infused for each liter >5L removed to prevent ________.
6-8g albumin Kidney injury
46
Who gets liver transplants for cirrhosis?
Patients with decompensated cirrhosis and a MELD score ≥15 Requires 6 months abstinence before can be considered for transplant Begin AA immediately
47
If a patient with alcoholic cirrhosis continues to drink...
4 year survival with a major complication is <20%
48
Complications of cirrhosis
Portal HTN Spontaneous bacterial peritonitis - once they’ve had one episode, should be given abx prophylaxis after d/c Hepatic encephalopathy Hepatorenal syndrome
49
Functional renal failure in the setting of decompensated cirrhosis
Hepatorenal syndrome
50
What are the two types of hepatorenal syndrome?
Type 1 - rapidly and progressive renal failure with severe multi-organ failure • Median survival ≤4 weeks • Prognosis: 3-month probably of survival 10% Type 2 - usually associated with refractory ascites • Median survival ~6 months (better but still bad)
51
Diagnostic criteria for hepatorenal syndrome
Cirrhosis with ascites Absence of shock Renal impairment (inc Cr of 0.3mg/dL within 48 hours or 50% inc from baseline within 7 days) No improvement with correction of volume status + albumin x 2 days Absence of other causes of AKI
52
Clinical features of hepatorenal syndrome
``` Ascites Serum Creatinine levels >1.5 mg/dL Azotemia (increased BUN)**** Oliguria (urine volume <500 ml/d) Hyponatremia (<130 mEq/L) Hypotension ```
53
How do you prevent hepatorenal syndrome?
Use albumin IV with large volume paracentesis Protect against GI bleeding with EGD surveillance or beta blocker use Do not use NSAIDs or supplements SBP prophylaxis • Pt with previous Hx of SBP • Pt with variceal bleed x 3-7 days • Pt with ascetic protein <1.5 g/dL
54
Why do you still need to exclude other diseases of acute/chronic liver disease with serologic testing +/- liver bx in patients who are chronic alcoholics?
As many as 20% of alcoholics have a secondary or co-existing etiology of liver disease
55
What are the three categories of liver masses?
Benign lesions —> no further testing required Benign lesions —> that need further investigation/therapy Malignant lesions requiring appropriate management
56
What is considered a benign liver lesion?
Cavernous hemangioma <4 cm Focal nodular hyperplasia Simple cyst <4 cm and asymptomatic Focal fatty change/sparing
57
________ are associated with use of oral birth control pills
Adenoma (malignant potential only 5% but increased risk of bleeding)
58
Benign liver lesions that require further management
Adenoma Liver abscess (pyogenic, amebic) Inflammatory pseudo tumor Atypical/complex cysts and large symptomatic simple cysts Refer to GI/Hep for further workup to confirm Dx and recommend treatment
59
Which malignancy is considered the Great Masquerader?
Lymphoma
60
What are the three types of primary liver neoplasm
Hepatocellular carcinoma (in the liver cells themself) Cholangiocarcinoma (in bile ducts) Other rare tumors (cystadenocarcinoma, angiosarcoma)
61
Neoplasms arising from parenchymal cells of the liver
Hepatocellular carcinoma
62
Neoplasms arising from biliary duct cells
Cholangiocarcinomas
63
You should have a high index of suspicions of HCC in what patients?
Cirrhotic patients Patients with non-cirrhotic Hep B with liver lesion on imaging
64
Who is at risk for HCC
All suspected cirrhotic patients from any liver disease Chronic Hep B
65
Sx of HCC
Cachexia, weakness, and weight loss Sudden appearance of ascites Elevated Alk Phos Elevated alpha-fetoprotein******
66
What diagnostic tests do you want for HCC?
Tri-phasic CT scan first If non-diagnostic then tri-physic MRI with gadolinium based contrast Liver biopsy is diagnostic, but may not need if imaging is typical and AFP is elevated
67
Screening of cirrhotic patients with US imaging and AFP should occur...
Q 6 months
68
How is HCC managed?
Resection rarely feasible due to background cirrhosis Liver transplant evaluation for early stage cancer • 1 lesion up to 5 cm or 3 lesions up to 3 cm AND no vascular invasion or distant spread RFA for small tumors in non-operative candidates TACE/TARE or XRT for large tumors if sufficient hepatic reserve

Clin Med III Unit 2 (6 decks)

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