Alcohol-related Liver Disease Flashcards
Give a brief overview of the pathogenesis of alcohol related liver disease.
Spectrum of liver disease ranges from reversible fatty change to end stage cirrhosis.
The spectrum ranges from alcoholic fatty liver (steatosis) to alcoholic hepatitis and chronic cirrhosis.
Describe the pathogenesis of Fatty Liver Disease.
- Alcohol is converted to acetaldehyde by the mitochondrial enzyme alcohol dehydrogenase.
- Acetaldehyde is converted in turn to acetate and then to fatty acids.
- Alcohol is calorie rich, fat is deposited in the liver (steatosis) initially around the central veins (zone 3) and then later around parenchyma.
If alcohol consumption ceases the liver will return to normal.
•If not inflammation and fatty change occurs (steatohepatitis).
Fibrosis, initially around central veins, may occur leading to cirrhosis in some patients.
Describe the pathogenesis of alcohol related cirrhosis.
Cirrhosis related to alcohol consumption is typically micron ocular with steatosis.
In some patients little evidence of steatosis is present.
If alcohol consumption ceases the cirrhosis may become macronodular with little inflammatory change.
Describe the pathogenesis of acute alcoholic hepatitis.
In addition to fatty change, may be infiltration with polymorphonuclear leukocytes and hepatic necrosis.
⏩hepatomegaly, fever, abdo pain, jaundice and hepatic decompensation.
Acute alcoholic hepatitis.
May occur on a background of cirrhosis of in those without underlying cirrhosis.
Liver may return to normal with nutritional support and abstinence from alcohol.
What would a patient with alcoholic liver disease describe in their history?
May remain asymptomatic and undetected unless they present for other reasons.
May be mild illness with nausea, malaise, epigastric or right hypochondrial pain and a low-grade fever.
May be more severe with jaundice, abdominal discomfort or swelling, swollen ankles or GI bleeding.
Women tend to present with more florid illness than men.
There is a history of heavy alcohol intake (~15–20 years of excessive intake necessary for development of alcoholic hepatitis).
There may be trigger events (e.g. aspiration pneumonia or injury).
What would be found on examination of a patient with excessive alcohol intake?
Signs of alcohol excess: •Malnourished, •palmar erythema, •Dupuytrens contracture, •facial telangiectasia, •facial mooning •parotid enlargement, •spider naevi, •gynaecomastia, •testicular atrophy, •hepatomegaly, •smell of alcohol •easy bruising.
What would be found on examination of a patient with severe alcoholic hepatitis?
Signs of severe alcoholic hepatitis: •Febrile (50% of patients), •tachycardia, •jaundice (>50% of patients), •bruising, •encephalopathy (e.g. hepatic foetor, liver flap, drowsiness, unable to copy a five-pointed star, disoriented), •ascites (30–60% of patients), •hepatomegaly (liver is usually mild–moderately enlarged and may be tender on palpation), •splenomegaly.
What is the definition of alcoholic hepatitis?
Inflammatory liver injury caused by chronic heavy intake of alcohol.
What investigations would you perform on a patient with suspected alcoholic hepatitis?
Blood:
•FBC: ⬇️ Hb, ⬆️ MCV, ⬆️ WCC, ⬇️ platelets.
•LFT (⬆️ transminases, ⬆️ bilirubin, ⬇️ albumin, ⬆️ AlkPhos, ⬆️ GGT).
•U&E: Urea and K+ levels tend to be low, unless significant renal impairment.
•Clotting: Prolonged PT is a sensitive marker of significant liver damage.
Ultrasound scan:
For other causes of liver impairment (e.g. malignancies).
Upper GI endoscopy:
To investigate for varices.
Liver biopsy:
Percutaneous or transjugular (in the presence of coagulopathy) may be helpful to distinguish from other causes of hepatitis.
Electroencephalogram:
For slow-wave activity indicative of encephalopathy.
How would you manage a patient with alcoholic hepatitis?
Acute:
•Thiamine,
•Vitamin C and other multivitamins (initially parenterally).
•Monitor and correct K+ , Mg2+ and glucose abnormalities.
•Ensure adequate urine output.
•Treat encephalopathy with oral lactulose and phosphate enemas.
•Ascites is managed by diuretics (spironolactone with or without frusemide (furosemide)) or therapeutic paracentesis.
•Glypressin and N-acetylcysteine for hepatorenal syndrome.
Nutrition:
•Nutritional support with oral or nasogastric feeding is important with increased caloric intake.
•Protein restriction should be avoided unless the patient is encephalopathic.
•Total enteral nutrition may also be considered as this improves mortality rate.
•Nutritional supplementation and vitamins (B group, thiamine, folic acid) should be started parenterally initially and then continued orally after.
Steroid therapy:
•Meta-analyses show that steroids reduce short-term mortality for severe alcoholic hepatitis.
Long-term:
See Alcohol dependence.
What complications are associated with alcoholic hepatitis?
- Acute liver decompensation,
- hepatorenal syndrome (renal failure secondary to advanced liver disease),
- cirrhosis
What is the prognosis for a patient with alcoholic hepatitis?
Mortality in first month is about 10%; 40% in first year.
If alcohol intake continues, most progress to cirrhosis within 1–3 years.
Various validated prognostic scores can be used:
•Maddreys discriminant function (MDF)
•Glasgow alcoholic hepatitis score (GAHS)
What is the definition of alcohol dependence?
Alcohol dependence is characterized by three or more of:
•Withdrawal on cessation of alcohol.
•Tolerance.
•Compulsion to drink, difficulty controlling termination or the levels of use.
•Persistent desire to cut down or control use.
•Time is spent obtaining, using, or recovering from alcohol.
•Neglect of other interests (social, occupational, or recreational).
•Continued use despite physical and psychological problems.
Recommended limits for F and M are 14 and 21 units/week, respectively.
What questions should you ask if you are screening for alcohol dependence?
CAGE screening questions:
•Cut-down: … felt that you should cut-down on intake?
•Annoyed: … felt annoyed by criticism of your drinking?
•Guilt: … felt guilty about how much you drink?
•Eye-opener:… feel that you need a drink when you wake up?
Evaluate for associated comorbidities including smoking, other substance abuse, depression, anxiety and panic attacks.
What would a patient suffering with alcohol dependence describe in their history?
•acute intoxication
•symptoms of withdrawal?
Acute intoxication:
Amnesia, ataxia, dysarthria, disorientation, palpitations, flushing and
coma.
Symptoms of withdrawal:
Nausea, sweating and tremor, restlessness, agitation, visual
hallucination, confusion, seizures.
