Alcoholic Hepatitis

Question 1

What is alcoholic hepatitis?

Answer 1

Inflammatory liver injury caused by chronic heavy intake of alcohol

Question 2

What are the 3 forms of liver disease that can occur from excessive alcohol consumption?

Answer 2

1. Alcoholic fatty liver (steatosis)
2. Alcoholic hepatitis
3. Chronic cirrhosis

Question 3

What are the histopathological features of alcohol hepatisitis?

Answer 3

• Centrilobular ballooning
• Degeneration and necrosis of hepatocytes
• Steatosis – fatty change
• Neutrophilic inflammation
• Cholestasis – condition in which bile cannot flow from liver to the duodenum
• Mallory-hyaline inclusions (eosinophilic intracytoplasmic aggregates of cytokeratin intermediate filaments)
• Giant mitochondria

Question 4

Summarise the epidemiology of alcoholic hepatitis

Answer 4

Occurs in 10-35% of heavy drinkers

Question 5

What are the presenting symptoms of alcoholic hepatitis?

Answer 5

May remain asymptomatic and undetected
1. May be mild illness with symptoms such as:
- Nausea
- Malaise
- Epigastric pain
- Right hypochondrial pain
- Low-grade fever
2. More severe presenting symptoms include:
- Jaundice
- Abdominal discomfort or swelling
- Swollen ankles
- GI bleeding
NOTE: a long history of heavy drinking is required for the development of alcoholic hepatitis (around 15-20 years)
- There may be events that trigger the disease (e.g. aspiration pneumonia, injury)

Question 6

What signs of alcoholic hepatitis can be found on physical examination?

Answer 6

1. Signs of Alcohol Excess
   - Malnourished
   - Palmar erythema
   - Dupuytren’s contracture
   - Facial telangiectasia – red lines appear due to widened venules
   - Parotid enlargement
   - Spider naevi
   - Gynaecomastia
   - Testicular atrophy
   - Hepatomegaly
   - Easy bruising
2. Signs of Severe Alcoholic Hepatitis
   - Febrile (in 50% of patients)
   - Tachycardia
   - Jaundice
   - Bruising
   - Encephalopathy (e.g. liver flap, drowsiness, disorientation) – caused by build up of ammonia in blood (which is normally removed by the liver) – crosses blood-brain barrier
   - Ascites
   - Hepatomegaly
   - Splenomegaly

Question 7

What investigations are used to diagnose/ monitor alcoholic hepatisitis?

Answer 7

1. (liver enzymes- released by degenerating hepatocytes) AST>ALT (2:1) (Make a toAST with alcohol) (both increased)
2. Elevated GGT (particularly in absence of raised ALP → suggests alcohol abuse)
3. FBC → non-megaloblastic macrocytic anaemia (sign of alcoholic liver disease)
4. Increased ALP (but to lesser degree than AST and ALT)
5. Increased Bilirubin, Decreased Albumin
6. Increased PT → sensitive marker of significant liver damage. Clotting factors 2,7,9,10 are made by the liver (mainly affect PT but also APTT).
7. Ultrasound → check for other causes of liver impairment (malignancy)

Question 8

How is alcoholic hepatitis managed?

Answer 8

1. Acute → thiamine (prevent wernicke’s encephalopathy), vitamin C, pabrinex
2. Withdrawal Management → chlordiazepoxide (if have symptoms of withdrawal)
3. Steroid Therapy (Corticosteroids - prednisolone) → reduces short-term mortality for severe alcoholic hepatitis
4. Immediate cessation of alcohol use
5. Nutrition: NG feeding, nutritional supplementation and vitamins

Question 9

What are some signs a patient is experiencing alcohol withdrawal syndrome?

Answer 9

1. Seizures:
   - tonic-clonic
2. Alcoholic hallucinosis
   - most often visual
3. Delirium tremens: potentially fatal
   - extreme hypertension
   - tremors
   - seizures
   - disorientation
   - hallucinations

Question 10

What is hepatorenal syndrome?

Answer 10

“The development of renal failure in patients secondary to advanced chronic liver disease”
- Thought to arise because of abnormalities in blood vessel tone in the kidneys
- Blood vessels in the kidney constrict because of the dilatation of blood vessels in the splanchnic circulation (supplying the intestines), which is mediated by factors released by liver disease – e.g. nitric oxide, prostaglandins
- The splanchnic vasodilation leads to reduced effective volume of blood detected by the juxtaglomarular apparatus, leading to activation of the RAS and vasoconstriction of vessels in the kidney
- This leads to kidney failure

Question 11

Identify the possible complications of alcoholic hepatitis

Answer 11

Acute liver decompensation
Hepatorenal syndrome
Cirrhosis

Question 12

Summarise the prognosis for patients with alcoholic hepatitis

Answer 12

1. Mortality:
   - First month = 10%
   - First year = 40%
2. If alcohol intake continues, most will progress to cirrhosis within 1-3 years
3. To calculate prognostic score can use Maddrey’s discriminant function or Glasgow alcoholic hepatitis score