Alcoholic hepatitis

Question 1

Define alcoholic hepatitis

Answer 1

Inflammatory liver injury caused by heavy intake of alcohol

Question 2

Aetiology of alcoholic hepatitis

progression, history, trigger

Answer 2

1 of the 3 forms of liver disease caused by excessive alcohol intake:
Alcoholic fatty liver (steatosis) ->
Alcoholic hepatitis —>
Chronic cirrhosis

Long history (15-20 yrs) of heavy drinking required

May be events that trigger the disease (e.g. aspiration pneumonia, injury)

Question 3

Histopathological features of alcoholic hepatitis

7

Answer 3

Centrilobular balooning 
Degeneration & necrosis of hepatocytes
Steatosis
Neutrophilic inflammation
Cholestasis
Mallory-hyaline inclusions
Giant mitochondria

Question 4

Epidemiology of alcoholic hepatitis

Answer 4

Occurs in 10-35% heavy drinkers

Question 5

Presenting symptoms of alcoholic hepatitis

general, 5 mild, 4 severe

Answer 5

May remain asymptomatic & undetected

Mild illness
Nausea
Malaise
Epigastric pain
Right hypochondriac pain
Low grade fever

More severe
Jaundice
Abdominal discomfort or swelling
Swollen ankles 
GI bleeding

Question 6

Signs of alcohol excess on physical examination

10

Answer 6

Malnourished
Palmar erythema
Dupuytren’s contracture
Facial telangiectasia
Parotid enlargement  
Spider naevi
Gynaecomastia
Testicular atrophy
Hepatomegaly
Easy bruising

Question 7

Signs of alcoholic hepatitis on physical examination

8

Answer 7

Febrile (50% patients)
Tachycardia
Jaundice
Bruising 
Encephalopathy 
Ascites
Hepatomegaly 
Splenomegaly

Question 8

Investigations for alcoholic hepatitis

5

Answer 8

Bloods
US
Upper GI endoscopy
Liver biopsy
EEG

Question 9

Investigations for alcoholic hepatitis - bloods

4

Answer 9

FBC
low Hb, high MCV, high WCC, low platelets

LFTs
high AST & ALT, high bilirubin, high ALP & GGT, low albumin

U&Es
urea & K+ tend to be low

Clotting
prolonged PT is sensitive marker for significant liver damage

Question 10

Investigations for alcoholic hepatitis - US

Answer 10

Check for other causes of liver impairment (e.g. malignancy)

Question 11

Investigations for alcoholic hepatitis - upper GI endoscopy

Answer 11

Investigate varices

Question 12

Investigations for alcoholic hepatitis - liver biopsy

Answer 12

Can help distinguish from other causes of hepatitis

Question 13

Investigations for alcoholic hepatitis - EEG

Answer 13

Slow wave activity indicated encephalopathy

Question 14

Management of alcoholic hepatitis

3

Answer 14

Acute
Nutrition
Steroid therapy

Question 15

Management of alcoholic hepatitis - acute

8

Answer 15

Thiamine
Vitamin C & other multivitamins (Pabrinex)
Monitor & correct K+, Mg2+ & glucose
Ensure adequate urine output
Treat encephalopathy w/ oral lactulose or phosphate enemas
Ascites managed w/ diuretics (spironolactone w/w/o furosemide)
Therapeutic paracentesis
Glypressin & N-acetylcysteine for hepatorenal syndrome

Question 16

Management of alcoholic hepatitis - nutrition

3

Answer 16

Oral or NG feeding important
Protein restriction should be avoided unless patient is encephalopathic
Nutritional supplementation & vitamins (B, thiamine & folic acid) should be started parenterally & cont. orally

Question 17

Management of alcoholic hepatitis - steroid therapy

Answer 17

Reduces short term mortality for severe alcoholic hepatitis

Question 18

Complications of alcoholic hepatitis

3

Answer 18

Acute liver decompensation
Hepatorenal syndrome
Cirrhosis

Question 19

Definition & aetiology of hepatorenal syndrome

1 + 4

Answer 19

Development of renal failure in patients w/ advanced chronic liver disease

Thought to arise due to abnormalities in blood vessel tone in kidneys
Blood vessels in kidneys constrict because of dilatation of blood vessels in splanchnic circuit (supplying intestines), mediated by factors released by the kidneys
Leads to reduced effective volume of blood detected by juxtaglomerular apparatus, leading to activation of RAS & vasoconstriction of vessels in kidney
Lead to kidney failure

Question 20

Prognosis of alcoholic hepatitis

2

Answer 20

Mortality 10% 1st month to 40% in 1st year

If alcohol intake continues, most will progress to cirrhosis in 1-3 yrs