Alcohol Related Liver Disease Flashcards
List some of the conditions of the liver that alcohol causes
Alcoholic hepatitis
Encephalopathy
Sponstaneous Bacterial Peritonitis
Fatty Liver Disease
Do we all metabolise alcohol the exact same way?
No.
Genetic variation
Women metabolise slower than men
Describe the oxidative metabolism of ethanol
Ethanol converted to acetaldehyde by alcohol dehydrogenase.
Acetaldehyde converted to acetate by acetaldehyde dehydrogenase
Describe the microsomal enzyme oxidation system of ethanol
ethanol is converted to acetaldehyde by cytochrome P4502E1
Give two pathways alcohol blocks in metabolism
Fat metabolism (leading to fatty liver) Gluconeogenesis (may lead to hypoglycaemia)
What is steatosis?
Fatty Liver
What is steatohepatitis?
Inflammatory response to large fatty change in liver.
Neutrophil infiltration
Fibrosis and cirrhosis
What are the CAGE questions for taking an alcoholic history?
Have you ever felt the need to CUT down?
Have you ever been ANNOYED by criticism of your drinking?
Have you ever felt GUILTY about your drinking?
Do you need an EYEOPENER?
What is 1 unit of alcohol?
Half a pint of regular beer or cider
1 small glass of wine
25ml measure of spirits
1 small glass of sherry
What is FAST/AUDIT?
Questionnaire to asses alcoholic liver disease risk.
If FAST positive you carry out an AUDIT.
When do physical findings present in alcoholic liver disease?
Quite advanced disease
Majority often present with no physical signs
What are some of the signs of alcoholic liver disease?
Spider naevi, Palmar erythema Gynocomastia Loss of auxiliary and pubic hair Ascites Encephalopathy Jaundice (serious) Muscle wasting
What labs can you find in alcoholic liver disease?
Aspartate Amino Transferase (AAT) > Alanine Amino Transferase (ALT) RATIO >2
Raised Gamma Glutamyl Transferase
Macrocytosis
Thrombocytopenia (low platelets)
These aren’t necessarily diagnostic but are usually seen
What is macrocytosis?
Enlargement of RBC’s due to bone marrow dysplasia
Alcohol is toxic to the bone marrow
What clinical sign does cause Thrombocytopenia?
Petechia
What investigation will show a fatty liver?
USS
Fatty liver is invariably found in alcoholic disease
What is hepatic encephalopathy?
Confusion, altered levels of consciousness or coma
This is due to liver failure and a build up of toxins as a result
Graded 1-4
1 = Mild Confusion, 4 = Coma
What are the causes of encephalopathy?
Im Confused (because i) Eat Good Drugs
Infection Constipation Electrolyte disturbance GI Bleed Drugs
When someone presents with hepatic encephalopathy what should you exclude?
Infection (more common in alcoholics)
Hypoglycaemia (again associated with alcohol)
Intracranial bleed (may have fallen over if drunk)
What is the treatment for hepatic encephalopathy?
Bowel clear out, lactulose, enemas Antibiotics (infection screen) Supportive -ITU, airway support (coma) -Nasogastric tube for meds
How may someone present with spontaneous bacterial peritonitis?
ASCITES Abdominal pain Fever, rigors Renal impairment Signs of sepsis, tachycardia, temperature
How do you diagnose spontaneous bacterial peritonitis?
Ascetic tap
-Fluid and protein levels (protein 0.25x10^9/L)
What is the treatment for spontaneous bacterial peritonitis?
IV antibiotics
Ascitic fluid drainage
IV albumin infusion
What other causes of peritonitis must be excluded when someone presents with what you think is spontaneous bacterial peritonitis?
Surgical causes of peritonitis
How does alcoholic hepatitis present?
Jaundice Encephalopathy Infection common Decompensated hepatic function -Low albumin and increased prothrombin time/ INR)
How do you diagnose alcoholic hepatitis?
Raised bilirubin
Raised GGT and AlkP
Alcohol History (+jaundice then probably this)
Exclude other causes
What is the prognosis of alcoholic hepatitis?
Poor
40% mortality
if severe up to 90%
What is the treatment for alcoholic hepatitis?
Supportive Treat infection Treat encephalopathy Treat alcohol withdrawal Protect against GI bleed (risk of PU and Vatical bleed) Airway protection/ITU care
Steroids
Nutrition
When can you consider steroids in alcoholic hepatitis?
Severe disease
Large side effects so risk will only be less than benefit in severe disease.
Glasgow Alcoholic hepatitis score of >9
Modified Maddrey’s discriminant function >32
Then treat with oral steroids
What treatment is the most important in alcoholic hepatitis?
NUTRITION
100% of patients with alcoholic hepatitis are malnourished
33% severely
2 year survival increases from 15% to 70% if nourished
ABSOLUTE FUCKING SHIT TON OF THIAMINE
Frequent feeds, high energy requirement
(body working hard to repair liver)
Can you get steatosis not associated with alcohol?
Yes
Non-Alcoholic Fatty Liver Disease (NAFLD)
Can you get steatosis in a patient who doesn’t drink alcohol?
Yes
Non-Alcoholic Steatohepatitis (NASH)
How do patients present in NASH compared with alcohol associated steatohepatitis?
The same
What is the epidemiology of fatty liver and what are the causes?
25-40% of the population Obesity Diabetes Hypercholesterolaemia (alcohol)
?beinign
How many people with steatohepatitis will go on to develop cirrhosis?
How does this compare to steatosis?
Steatohepatitis -> cirrhosis =25%
Steatosis -> cirrhosis = 1-2%
How does steatohepatitis present?
What investigations can you carry out?
Asymptomatic
Raised Alanine Amino Transferase (AAT)
Fatty Liver on USS
Liver Biopsy
What are the treatments for steatohepatitis?
Exercise
Weightloss
