Alcohol Hepatitis Flashcards
define alcoholic hepatitis?
inflammatory liver injury caused by chronic heavy intake
what are the 3 forms of liver disease caused by excessive alcohol intake?
alcoholic fatty liver ( steatosis)
alcoholic hepatitis
chronic cirrhosis
what are the histopathological features of alcohol hepatitis?
centrilobular ballooning degeneration and necrosis of hepatocytes steatosis
fatty change neutrophillic
inflammation cholestasis- condition in which bile cannot flow from liver to duodenum mallor
hyaline inclusions ( eosinophilic intracytoplasmic aggregates of cytokeratin) giant mitochondria
summarise the epidemiology of alcoholic hepatitis?
occurs in 10-35% of heavy drinkers
patients with Hep C have more severe symptoms
what are the presenting symptoms of alcoholic hepatitis?
may remain asympyomatic and undetected
may be mild illness symptoms
- nausea
- malaise
- epigastric pain
- right hypochondrial pain
- low grade fever
sever presenting symptoms
- jaundice
- abdominal discomfort or swelling
- swollen
- GI bleeding-> Haematemesis + melaena
- long history of heavy drinking is required for the development of alcoholic hepatitis ( around 15-20 years)
What are the signs of alcoholic hepatitis on physical examination?
Signs of Alcohol Excess
- Malnourished => fatigue
- Palmar erythema
- Dupuytren’s contracture
- Facial telangiectasia– red lines appear due to widened venules
- Parotid enlargement
- Spider naevi
- Gynaecomastia
- Testicular atrophy
- Hepatomegaly
- Easy bruising
Signs of Severe Alcoholic Hepatitis
- Febrile (in 50% of patients)
- Tachycardia
- Jaundice
- Bruising
- Encephalopathy(e.g. liver flap, drowsiness, disorientation) – caused by build up of ammonia in blood (which is normally removed by the liver) – crosses blood-brain barrier
- Ascites
- Hepatomegaly
what are the appropriate investihations for alcoholic hepatitis?
FBC
LFTs
U and E
ultrasound- check for liver impairment ( malignancy)
What can be seen in a full blood count for alcoholic hepatitis?
low hb High MCV High WCC Low plate
what is encephalopathy in alcoholic hepatitis caused by?
liver flap, drowsiness, disorientaiton-> caused by build up of ammonia in blood ( which is normally removed by liver)- crosses blood-brain barrier
What will LFTs look like in alcoholic hepatitis?
High AST + ALT – ratio if AST/ALT is >2% (if ALT>AST then it may suggest viral hepatitis or NASH)
High bilirubin
High ALP + GGT
Low albumin
describe U and E in alcoholic hepatitis?
Urea and K+ tend to be low
what happens to clotting in alcoholic hepatitis?
prolonged PT->sensitive marker for significant liver damage
What investigations should you consider?
- Upper GI Endoscopy - investigate varices
- Serum antibodies (e.g. AMA, ANA, ASMA) to rule out AI hepatitis
- Viral hepatitis serology may be conducted to rule it out
- Liver Biopsy - can help distinguish from other causes of hepatitis
- EEG - slow-wave activity indicates encephalopathy
- CT/MRI abdomen – may show hepatomegaly, splenomegaly, ascites, portal vein engorgement
outline a management plant for alcoholic hepatitis?
Acute
- Thiamine
- Vitamin C and other multivitamins(can be given as Pabrinex)
- Monitor and correct K+, Mg2+ and glucose
- Ensure adequate urine output
- Treat encephalopathy with oral lactulose or phosphate enemas – decrease ammonia generation by bacteria
- Ascites - manage with diuretics(spironolactone with/without furosemide)
- Therapeutic paracentesis(removing fluid)
- Glypressin and N-acetylcysteine for hepatorenal syndrome
Nutrition
- Alcohol abstinence and alcohol withdrawal
- Via oral or NG feedingis important
- Protein restriction should be avoided unless the patient is encephalopathic
- For the ascites => Na restricted diet(when progresses –> diuretics also added)
- Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally
Imms – Influenza, pneumococcal, hep all recommended
Steroid Therapy (e.g. prednisolone)- reduce short-term mortality for severe alcoholic hepatitis
summatise the prognosis for patients with alcohol hepatitis?
Mortality:
- First month = 10%
- First year = 40%
If alcohol intake continues, most will progress to cirrhosis within 1-3 years
To calculate prognostic score can use Maddrey’s discriminant function or Glasgow alcoholic hepatitis score