Alcohol Related Disease

Question 1

Why can alcohol affect some people more so than others?

Answer 1

• Direct alcohol toxicity
Drinking enough in one sitting you can cause significant liver damage
• Genetic variation
Some people are much better than others and are therefore less likely to develop disease
• Women metabolise slower than men

Question 2

State two effects that alcohol can have on the liver

Answer 2

• Steatosis (fatty liver)

* Steatohepatitis (fatty liver with inflammation)

Question 3

Describe the features of steatohepatitis

Answer 3

• Neutrophil infiltration

* Fibrosis, cirrhosis (build-up of scar tissue)

Question 4

What are the four cage questions to ask in the history?

Answer 4

• Have you ever felt the need to Cut down?
• Have you been Annoyed by criticism of your drinking?
• Have you felt Guilty about your drinking?
• Do you need an Eye-opener?

Question 5

What are the signs of chronic liver disease?

Answer 5

Spider naevi, palmar erythema, gynaecomastia, loss of axillary and pubic hair, ascites, encephalopathy

Question 6

What are the physical findings seen with alcohol liver disease?

Answer 6

• Signs of chronic liver disease
• Jaundice
• Muscle wasting

Question 7

What is the Aspartate Amino Transferase (AAT) test?

Answer 7

AST is found in the highest concentrations in your liver, muscles, heart, kidney, brain and red blood cells. Abnormal levels can be associated with liver injury.

Test measures the amount of AST in your blood that has been released from injured tissue

Question 8

Describe the lab results your would expect to see in liver disease

Answer 8

• Aspartate Amino Transferase (AAT) > Alanine Amino Transferase (ALT). Ratio > 2
• Raised Gamma Glutamyl Transferase
• Macrocytosis
• Thrombocytopenia (low platelets)

Blood tests not specific to alcohol

Question 9

What investigations are used in liver disease?

Answer 9

• Labs - AST, AAT, GGT, blood count

* USS fatty liver

Question 10

What is the pathology behind hepatic encephalopathy?

Answer 10

• Liver failure

* Cannot process toxins properly and so leads to a build up of ammonia

Question 11

How is hepatic encephalopathy graded?

Answer 11

Graded 1-4:
• 1 - mild confusion
• 4 - coma

Question 12

Name 5 causes of hepatic encephalopathy

Answer 12

• Infection
• Drugs
• Constipation
• GI Bleed
• Electrolyte disturbance

Question 13

What is the treatment of hepatic encephalopathy?

Answer 13

• Bowel clear out, lactulose, enemas (constipation cause build-up of toxins from gut causing confusion)
• Antibiotics
• Supportive:
  o ITU, airway support
  o Nasogastric tube for meds

Question 14

What are three conditions you need to exclude before diagnosing hepatic encephalopathy?

Answer 14

• Infection
• Hypoglycaemia
• Intra-cranial bleed

Question 15

What is the complication of spontaneous bacterial peritonitis?

Answer 15

Ascites – build-up of fluid in abdomen and there is a risk of it becoming infected

Question 16

What is the presentation of spontaneous bacterial peritonitis present?

Answer 16

• Abdominal pain
• Fever, rigors
• Renal impairment
• Signs of sepsis, tachycardia, temperature

Question 17

What investigations are used for spontaneous bacterial peritonitis?

Answer 17

Ascitic tap:
• Fluid protein and glucose levels
• Cultures
• White cell count

Neutrophil count > 0.25x10^9 /L
Protein < 25g/L

Question 18

What is the treatment of spontaneous bacterial peritonitis?

Answer 18

• IV Antibiotics
• Ascitic Fluid Drainage
• IV Albumin Infusion (20% ALBA)

Question 19

How is the presentation of alcoholic hepatitis?

Answer 19

• Jaundice
• Encephalopathy
• Infection common
• Decompensated hepatic function (low albumin and raised prothrombin time/INR)

Question 20

What are diagnostic markers of investigations and history for alcoholic hepatitis?

Answer 20

• Raised bilirubin
• Raised GGT and AlkP
• Alcohol history
• Exclude other causes

Question 21

What is the treatment used for alcoholic hepatitis?

Answer 21

• Supportive
• Treat infection
• Treat encephalopathy
• Treat alcohol withdraw
• Protect against GI Bleeding
• Airway protection / ITU care

Steroids
• Glasgow alcoholic hepatitis score > 9

Nutritional:
• Thiamine
• Frequent feeds, high energy requirements - 100% are malnourished

Question 22

What is the problem with using steroids to treat alcoholic hepatitis?

Answer 22

Increase risk of GI bleeding and infection, therefore therapeutic benefit only in those with very low function

Question 23

What can alcoholic hepatitis progress to if left untreated?

Answer 23

Ongoing alcohol consumption:

Steatohepatitis –> cirrhosis

Question 24

Name two fatty liver conditions

Answer 24

Steatosis:
Fatty liver and can be unrelated to alcohol (non-alcoholic fatty liver NAFLD)

Steatohepatitis:
Can be unrelated to alcohol: non-alcoholic steatohepatitis (NASH)

Question 25

What are three causes of fatty liver disease?

Answer 25

• Obesity
• Diabetes
• Hypercholesterolaemia

Question 26

What is the presentation of steatohepatitis?

Answer 26

• Asymptomatic
• Raised alanine amino transferase
• Fatty liver on USS
• Liver biopsy – shows fat in tissue and levels of inflammatory markers in liver

Question 27

What is the treatment of steatohepatitis?

Answer 27

Weight loss – exercise and diet