Alcohol Related Liver Disease

Question 1

what is ethanol broken down into

Answer 1

acetaldehyde

Question 2

what is acetaldehyde

Answer 2

a toxic metabolite, toxic and carcinogenic

side effects include - flushing and nausea

Question 3

what is acetaldehyde broken down into

Answer 3

acetate

Question 4

what other metabolic pathways are affected by ethanol excess

Answer 4

excess lipids, lactic acid, ketones = acidosis

breakdown in gluconeogenesis and glycolysis pathway, glycogen not metabolised = hyperglycemia

Question 5

what effect does alcohol have on the appearance of the liver

Answer 5

steatosis
steatohepatitis

Question 6

steatosis

Answer 6

fatty liver

Question 7

steatohepatitis

Answer 7

fatty liver with inflammation

Neutrophil infiltration
Fibrosis, Cirrhosis (Build up of scar tissue)

Question 8

what questions must you ask the patient in relation to alcohol consumption

Answer 8

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 Eyeopener

Question 9

what is the scoring system used to assess alcohol intake

Answer 9

FAST

Question 10

what questions are rated 1-4 in FAST

Answer 10

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Only answer the following questions if the answer above is Never (0), Less than monthly (1) or Monthly (2). Stop here if the answer is Weekly (3) or Daily (4).
How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Question 11

how is the FAST scoring system scored

Answer 11

If score is 0, 1 or 2 on the first question
continue with the next three questions

If score is 3 or 4 on the first question – stop here.

An overall total score of 3 or more is FAST positive.

Question 12

what do you do if a patient is fast positive

Answer 12

What to do next?
If FAST positive, complete remaining AUDIT questions (this may include the three remaining questions above as well as the six questions on the second page) to obtain a full AUDIT score.

Question 13

what are the physical findings of someone with alcohol related liver disease

Answer 13

Majority no physical findings until advanced liver disease

Signs of chronic liver disease
Spider naevi, palmar erythema, gynaecomastia, loss of axillary and pubic hair, ascites, encephalopathy

Jaundice

Muscle wasting

Question 14

what lab results are found in a patient with alcohol related liver disease

Answer 14

Aspartate Amino Transferase (AAT) > alanine

Amino Transferase (ALT). Ratio >2

Raised Gamma Glutamyl Transferase

Macrocytosis

Thrombocytopenia (low platelets)

Question 15

what test is run for fatty liver

Answer 15

USS

Question 16

what is a feature of liver feature that is graded 1-4

Answer 16

hepatic encephalopathy

1- mild confusion
4- coma

Question 17

what are the causes of hepatic encephalopathy

Answer 17

Infection

Drugs

Constipation [bowel not cleareing build up of metabolites (ammonia), can cross bowel wall and go into bloood brain barrier causing confusion]

GI Bleed

Electrolyte Disturbance

Question 18

what alternative diagnosis must be exluded before diagnosing hepatic encephalopathy

Answer 18

Infection
Hypoglycaemia
Intra Cranial Bleed

Question 19

what is treatment for hepatic encephalopathy

Answer 19

Treatment
Bowel clear out, lactulose, enemas.

Antibiotics

Supportive
ITU, airway support
Nasogastric tube for meds

Question 20

what are the signs of Spontaneous Bacterial Peritonitis

Answer 20

Abdominal Pain

Fever, Rigors

Renal impairment

Signs of Sepsis, tachycardia, temperature

Question 21

what is the diagnostic process for Spontaneous Bacterial Peritonitis

Answer 21

Ascitic Tap
Fluid Protein and Glucose levels
Cultures
White Cell Content

Question 22

what should the ascitic tap show for Spontaneous Bacterial Peritonitis

Answer 22

Neutrophil Count >0.25x109 /L
Protein <25g/L

Question 23

what alternative diagnosis must be excluded before diagnosis Spontaneous Bacterial Peritonitis

Answer 23

Exclude surgical causes of peritonitis

Question 24

what is treatment for Spontaneous Bacterial Peritonitis

Answer 24

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

Question 25

what are presenting features of alcoholic hepatitis

Answer 25

Jaundice

Encephalopathy

Infection common

Decompensated hepatic function
(Low albumin and raised prothrombin time/INR)

Question 26

Alcoholic Hepatitis
diagnosis

Answer 26

Raised Bilirubin
Raised GGT and AlkP
Alcohol History
Exclude other causes

Question 27

what is the prognosis for alcoholic hepatitis

Answer 27

Poor Prognosis
40% Mortality
If severe up to 90% mortality

Question 28

what is the treatment options for alcoholic hepatitis

Answer 28

Supportive
Treat infection
Treat encephalopathy
Treat alcohol withdrawal
Protect against GI bleeding
Airway Protection / ITU care

Question 29

what treatment option is availble for alcoholic hepatitis if graded as severe

Answer 29

steriods

Question 30

how is alcoholic hepatitis graded

Answer 30

Glasgow Alcoholic Hepatitis Score >9

Maddreys discriminent function >32

Question 31

what are the nutritional treatment options for alcoholic hepatitis

Answer 31

100% patients with alcoholic hepatitis are malnourished, 33% severely
2 yr Survival 15% vs 70% if well nourished
Thiamine
Frequent Feeds, high energy requirement

Question 32

prognosis of alcholic hepatitis post treatment

Answer 32

Dependant on abstinence or ongoing alcohol consumption
Steatohepatitis&raquo_space;> Cirrhosis
Present any sign of decompensating liver disease 70% mortality in 5 years
Present with encephalopathy 64% 1 year mortality

Question 33

how is the appearance of a fatty liver described

Answer 33

Steatosis
Fatty liver, non alcoholic fatty liver (NAFLD)

Steatohepatitis
Non alcoholic steatohepatitis (NASH)

Question 34

how prevalent is fatty liver

Answer 34

25 -40% population

Question 35

what is the aetiology of fatty liver

Answer 35

Obesity
Diabetes
Hypercholesterolaemia
(alcohol)

?Benign

Question 36

Steatohepatitis

Answer 36

Fat + Inflammation

Histology similar to alcohol induced damage

¼ Develop cirrhosis

Question 37

Steatohepatitis

Answer 37

Asymptomatic
Raised Alanine amino transferase
Fatty liver on USS
Liver Biopsy

Treatment
Weight Loss, exercise