Alcoholic hepatitis Flashcards
Define alcoholic hepatitis
Inflammatory liver injury caused by heavy intake of alcohol
Aetiology of alcoholic hepatitis
progression, history, trigger
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)
Histopathological features of alcoholic hepatitis
7
Centrilobular balooning Degeneration & necrosis of hepatocytes Steatosis Neutrophilic inflammation Cholestasis Mallory-hyaline inclusions Giant mitochondria
Epidemiology of alcoholic hepatitis
Occurs in 10-35% heavy drinkers
Presenting symptoms of alcoholic hepatitis
general, 5 mild, 4 severe
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
Signs of alcohol excess on physical examination
10
Malnourished Palmar erythema Dupuytren’s contracture Facial telangiectasia Parotid enlargement Spider naevi Gynaecomastia Testicular atrophy Hepatomegaly Easy bruising
Signs of alcoholic hepatitis on physical examination
8
Febrile (50% patients) Tachycardia Jaundice Bruising Encephalopathy Ascites Hepatomegaly Splenomegaly
Investigations for alcoholic hepatitis
5
Bloods US Upper GI endoscopy Liver biopsy EEG
Investigations for alcoholic hepatitis - bloods
4
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
Investigations for alcoholic hepatitis - US
Check for other causes of liver impairment (e.g. malignancy)
Investigations for alcoholic hepatitis - upper GI endoscopy
Investigate varices
Investigations for alcoholic hepatitis - liver biopsy
Can help distinguish from other causes of hepatitis
Investigations for alcoholic hepatitis - EEG
Slow wave activity indicated encephalopathy
Management of alcoholic hepatitis
3
Acute
Nutrition
Steroid therapy
Management of alcoholic hepatitis - acute
8
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
Management of alcoholic hepatitis - nutrition
3
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
Management of alcoholic hepatitis - steroid therapy
Reduces short term mortality for severe alcoholic hepatitis
Complications of alcoholic hepatitis
3
Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
Definition & aetiology of hepatorenal syndrome
1 + 4
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
Prognosis of alcoholic hepatitis
2
Mortality 10% 1st month to 40% in 1st year
If alcohol intake continues, most will progress to cirrhosis in 1-3 yrs
