Alcohol Related Liver Disease

Question 1

List some of the conditions of the liver that alcohol causes

Answer 1

Alcoholic hepatitis
Encephalopathy
Sponstaneous Bacterial Peritonitis
Fatty Liver Disease

Question 2

Do we all metabolise alcohol the exact same way?

Answer 2

No.
Genetic variation
Women metabolise slower than men

Question 3

Describe the oxidative metabolism of ethanol

Answer 3

Ethanol converted to acetaldehyde by alcohol dehydrogenase.

Acetaldehyde converted to acetate by acetaldehyde dehydrogenase

Question 4

Describe the microsomal enzyme oxidation system of ethanol

Answer 4

ethanol is converted to acetaldehyde by cytochrome P4502E1

Question 5

Give two pathways alcohol blocks in metabolism

Answer 5

Fat metabolism (leading to fatty liver)
Gluconeogenesis (may lead to hypoglycaemia)

Question 6

What is steatosis?

Answer 6

Fatty Liver

Question 7

What is steatohepatitis?

Answer 7

Inflammatory response to large fatty change in liver.

Neutrophil infiltration
Fibrosis and cirrhosis

Question 8

What are the CAGE questions for taking an alcoholic history?

Answer 8

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?

Question 9

What is 1 unit of alcohol?

Answer 9

Half a pint of regular beer or cider
1 small glass of wine
25ml measure of spirits
1 small glass of sherry

Question 10

What is FAST/AUDIT?

Answer 10

Questionnaire to asses alcoholic liver disease risk.

If FAST positive you carry out an AUDIT.

Question 11

When do physical findings present in alcoholic liver disease?

Answer 11

Quite advanced disease

Majority often present with no physical signs

Question 12

What are some of the signs of alcoholic liver disease?

Answer 12

Spider naevi,
Palmar erythema
Gynocomastia
Loss of auxiliary and pubic hair
Ascites
Encephalopathy 
Jaundice (serious)
 Muscle wasting

Question 13

What labs can you find in alcoholic liver disease?

Answer 13

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

Question 14

What is macrocytosis?

Answer 14

Enlargement of RBC’s due to bone marrow dysplasia

Alcohol is toxic to the bone marrow

Question 15

What clinical sign does cause Thrombocytopenia?

Answer 15

Petechia

Question 16

What investigation will show a fatty liver?

Answer 16

USS

Fatty liver is invariably found in alcoholic disease

Question 17

What is hepatic encephalopathy?

Answer 17

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

Question 18

What are the causes of encephalopathy?

Answer 18

Im Confused (because i) Eat Good Drugs

Infection
Constipation
Electrolyte disturbance
GI Bleed
Drugs

Question 19

When someone presents with hepatic encephalopathy what should you exclude?

Answer 19

Infection (more common in alcoholics)
Hypoglycaemia (again associated with alcohol)
Intracranial bleed (may have fallen over if drunk)

Question 20

What is the treatment for hepatic encephalopathy?

Answer 20

Bowel clear out, lactulose, enemas
Antibiotics (infection screen)
Supportive
-ITU, airway support (coma)
-Nasogastric tube for meds

Question 21

How may someone present with spontaneous bacterial peritonitis?

Answer 21

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

Question 22

How do you diagnose spontaneous bacterial peritonitis?

Answer 22

Ascetic tap

-Fluid and protein levels (protein 0.25x10^9/L)

Question 23

What is the treatment for spontaneous bacterial peritonitis?

Answer 23

IV antibiotics
Ascitic fluid drainage
IV albumin infusion

Question 24

What other causes of peritonitis must be excluded when someone presents with what you think is spontaneous bacterial peritonitis?

Answer 24

Surgical causes of peritonitis

Question 25

How does alcoholic hepatitis present?

Answer 25

Jaundice
Encephalopathy
Infection common
Decompensated hepatic function
-Low albumin and increased prothrombin time/ INR)

Question 26

How do you diagnose alcoholic hepatitis?

Answer 26

Raised bilirubin
Raised GGT and AlkP
Alcohol History (+jaundice then probably this)
Exclude other causes

Question 27

What is the prognosis of alcoholic hepatitis?

Answer 27

Poor
40% mortality
if severe up to 90%

Question 28

What is the treatment for alcoholic hepatitis?

Answer 28

Supportive
Treat infection
Treat encephalopathy
Treat alcohol withdrawal
Protect against GI bleed (risk of PU and Vatical bleed)
Airway protection/ITU care

Steroids
Nutrition

Question 29

When can you consider steroids in alcoholic hepatitis?

Answer 29

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

Question 30

What treatment is the most important in alcoholic hepatitis?

Answer 30

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)

Question 31

Can you get steatosis not associated with alcohol?

Answer 31

Yes

Non-Alcoholic Fatty Liver Disease (NAFLD)

Question 32

Can you get steatosis in a patient who doesn’t drink alcohol?

Answer 32

Yes

Non-Alcoholic Steatohepatitis (NASH)

Question 33

How do patients present in NASH compared with alcohol associated steatohepatitis?

Answer 33

The same

Question 34

What is the epidemiology of fatty liver and what are the causes?

Answer 34

25-40% of the population
Obesity
Diabetes
Hypercholesterolaemia
(alcohol)

?beinign

Question 35

How many people with steatohepatitis will go on to develop cirrhosis?
How does this compare to steatosis?

Answer 35

Steatohepatitis -> cirrhosis =25%

Steatosis -> cirrhosis = 1-2%

Question 36

How does steatohepatitis present?

What investigations can you carry out?

Answer 36

Asymptomatic

Raised Alanine Amino Transferase (AAT)
Fatty Liver on USS
Liver Biopsy

Question 37

What are the treatments for steatohepatitis?

Answer 37

Exercise

Weightloss