Alcohol related disease Flashcards
What is Steatosis?
the earliest, most common response of the liver to excessive alcohol consumption
excess lipids within the liver tissue + disrupted metabolism
What are the major ethanol metabolising enzymes called? (2)
alcohol dehydrogenase
cytochrome P450 2E1
What is steatohepatitis?
More serious condition that often continues on from steatosis
it is fatty liver with an inflammatory response too
- have neutrophil infiltration
- fibrosis, cirrhosis
What is CAGE? Used in history taking - alcohol consumption
Questions to find out if person is dependent on alcohol- can have alcohol damage without dependency
Cut down
Annoyed
Guilty
Eye opener (drink to wake you up in morning/ steady nerves)
What are the clinical signs of chronic liver disease? (8)
Spider naevi palmar erythema gynaecomastia loss of axillary and pubic hair ascites encephalopathy - brain damage/disease Jaundice muscle wasting - alcohol consumes your diet then reduced nutrients and so energy has to be taken from muscles
Lab tests to test liver function
Aspartate Amino Transferase (AAT) > alanine Amino Transferase (ALT) Ratio >2 indicates alcoholic liver disease
Raised Gamma Glutamyl Transferase - indicates damaged liver but could be many causes
Macrocytosis - enlarged RBC
Thrombocytopenia (low platelets)
if it’s to test synthetic liver function then prothrombin time - liver produces majority of coagulation proteins needed in blood clotting cascade. Severe liver injury leads to reduction of liver synthesis of clotting factors and consequently prolonged PT
What is hepatic Encephalopathy?
changes in the brain that occur in patients with advanced, acute or chronic liver disease
not unique to liver disease but feature of liver failure
Graded 1-4
Grade 1 Hepatic encephalopathy
mild confusion
Grade 4 Hepatic encephalopathy
Coma
Causes of Hepatic Encephalopathy (5)
increased NH3 due to liver not processing toxins efficiently - crosses B.B.B
Infection Drugs Constipation GI Bleed - varicses, ulcers due to high pressure - proteins leaking into gut - NH3 Electrolyte Disturbance
Treatment for Hepatic Encephalopathy (3)
Bowel clear out - lactulose (oral or enema) - dramatically reduces amount of NH3 in system
Antibiotics - tend to have infection somewhere
Supportive (confusion, coma etc) - (intensive treatment unit) ITU, airway support, nasogastric tube for meds
How does lactulose help with Hepatic Encephalopathy
reduces the amount of NH3 in the blood of patients with liver disease. It draws NH3 from the blood into the colon where it is removed from the body
What symptoms can a spontaneous bacterial peritonitis cause? (4)
liver failure - usually presence of ascites - extreme distension - can become infected and cause peritonitis
abdominal pain
fever, rigors
renal impairment
signs of sepsis - tachycardia, temperature
What is an Ascitic Tap?
medical procedure where a needle is used to drain ascitic fluid from the abdomen
fluid protein and glucose levels can be measured
cultures
white cell content important to indicate whether infection is present
What neutrophil count or protein level would you expect for a spontaneous bacterial peritonitis?
Neutrophil Count >0.25x109 /L
Protein <25g/L
Treatment for spontaneous bacterial peritonitis? (3)
IV antibiotics
Ascitic fluid drainage
IV albumin infusion
some may get dialysed temporarily to treat infection
How does a patient present with alcoholic hepatitis
Jaundice
Encephalopathy
Infection common
Decompensated hepatic function
What indicates a decompensated hepatic function
Low albumin and raised prothrombin time (becomes prolonged as liver doesn’t release clotting factors)
What is the prognosis like for alcoholic hepatitis?
poor
40% mortality
90% if severe
Treatment for alcoholic hepatitis?
supportive - abstinence + nutrition treat infection treat encephalopathy treat alcohol withdrawal airway protection/ ITU care
Glasgow alcohol hepatitis grading score - what is it? what does it take into consideration?
simple bedside tool to determine whether patient is high risk of severe alcoholic hepatitis - this is used over Maddrey’s
Age, WCC, Urea, INR, Bilirubin
score >9 means severe
Treatment options for low risk (<32 MDF) alcoholic hepatitis?
Nutritional support - v important
100% patients with alcoholic hepatitis are malnourished, 33% severely
2 yr Survival 15% vs 70% if well nourished
Thiamine (vit B1)
Frequent Feeds, liver has high energy requirement
Prognosis of mild/moderate alcoholic hepatitis
Dependant on abstinence or ongoing alcohol consumption
Having steatohepatitis and continuing to drink leads to liver cirrhosis but if you stop at mild/moderate injury then the liver is good at remodelling
Steatosis and steatohepatitis can affect individuals who don’t drink excessively as well. What are 2 disease examples of this?
non alcoholic fatty liver
non alcoholic steatohepatitis
Fatty liver disease is mostly associated with obesity - what factors related to obesity contribute to fatty liver?
diabetes
hypercholesterolaemia
alcohol - some alcoholic patients are also obese
True or false: fatty liver mechanism is very similar to alcohol
True
histology similar to alcohol induced damage
1/4 people with non alcoholic steatohepatitis will develop cirrhosis
genetic variation: alcohol processing in the liver
some are better at processing alcohol than others due to genetic makeup
What are some outcomes of alcohol interrupting normal metabolism
hypoglycaemia (gluconeogenesis knocked off) acidosis ketosis (interrupted CAC) excess lipids NADH + H+
How is alcoholic hepatitis diagnosed?
no simple diagnostic test check bilirubin levels (raised) GGT and AlkP (raised) Alcohol history Exclude other causes like gallstones, viral hepatitis
treatment for high risk patient ie severe alcoholic hepatitis?
oral steroids - only given for severe disease due to risk of GI bleed etc
prognosis for severe alcoholic hepatitis?
very poor
with encephalopathy 64% die within 1 year
tests for non-alcoholic steatohepatitis?
Alanine ratio
USS
biopsy
What is Spontaneous bacterial peritonitis?
a common complication of cirrhosis
infection in ascitic fluid
