Alcoholic Hepatitis Flashcards
Alcoholic Hepatits: What is it?
Alcohol-related liver disease= liver damage due to chronic excessive alcohol consumption. The damage occurs in stages.
Alcoholic Hepatitis: Pathophys.
1.Alcoholic fatty liver(also calledhepatic steatosis)
Drinking leads to a build-up of fat in the liver. This process is reversible with abstinence.
2.Alcoholic hepatitis
Chronic drinking pr binge drinking causes inflammation of hepatocytes. Mild alcoholic hepatitis is usually reversible with permanent abstinence.
3.Cirrhosis
Cirrhosis is where the functional liver tissue is replaced with scar tissue. It is irreversible and has poor prognosis if drinking continues. Stopping drinking can prevent further damage.
Alcoholic Hepatitis: Investigations
Blood test resultssuggesting alcohol-related liver disease include:
- Raisedmean cell volume(MCV)
- Raisedalanine transaminase(ALT) andaspartate transferase(AST)
- AST:ALT ratioabove 1.5 particularly suggests alcohol-related liver disease
- Raisedgamma-glutamyl transferase(gamma-GT) (particularly notable withalcohol-relatedliver disease)
- Raisedalkaline phosphatase(ALP) later in the disease
- Raisedbilirubinin cirrhosis
- Lowalbumindue to reducedsynthetic functionof the liver
- Increasedprothrombin timedue to reducedsynthetic functionof the liver (reduced production of clotting factors)
- DerangedU&Esinhepatorenal syndrome
Liver ultrasoundmay show earlyfatty changeswith “increased echogenicity”. Later, it can show changes related tocirrhosis. Ultrasound is used to screen forhepatocellular carcinomain patients withcirrhosis.
Transient elastography(“FibroScan”) can be used to assess the elasticity of the liver using high-frequency sound waves. It helps determine the degree offibrosis(scarring).
Endoscopycan be used to assess for and treatoesophageal variceswhenportal hypertensionis suspected.
CT and MRI scanscan be used to look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites.
Liver biopsycan be used to confirm the diagnosis of alcohol-related hepatitis or cirrhosis, particularly in patients where steroid treatment is being considered for alcohol-related hepatitis.
Alcoholic Hepatitis: Management
The general principles of managing alcohol-related liver disease are:
- Stop drinkingalcohol permanently (drug and alcohol servicesare available for support)
- Psychological interventions(e.g.,motivational interviewingorcognitive behavioural therapy)
- Consider adetoxication regime
- Nutritional supportwithvitamins(particularlythiamine–vitamin B1) and ahigh-protein diet
- Corticosteroidsmay be considered to reduce inflammation insevere alcoholic hepatitisto improveshort-termoutcomes (but not long-term outcomes)
- Treat complicationsof cirrhosis (e.g., portal hypertension, varices, ascites and hepatocellular carcinoma)
- Liver transplantin severe disease (generally 6 months of abstinence is required)
Alcohol Consumption
The UK recommendations on alcohol consumption:
- less than 14 units per week spread evenly over 3 or more days and not more than 5 units in a single day.
- Binge drinkingis defined as 6 or more units for women and 8 or more for men in a single session.
Pregnant women should avoid alcohol completely. Alcohol in early pregnancy can lead to:
- Miscarriage
- Small for dates
- Preterm delivery
- Fetal alcohol syndrome
Signs suggestive ofexcessive alcohol consumptioninclude:
- Smelling of alcohol
- Slurred speech
- Bloodshot eyes
- Dilated capillaries on the face (telangiectasia)
- Tremor
Alcohol Complications
- Alcohol-related liver disease incl. cirrhosis
- Cirrhosis and its complications (e.g., hepatocellular carcinoma)
- Alcohol dependence, tolerance and withdrawal
- Wernicke-Korsakoff syndrome (WKS)
- Pancreatitis
- Increased risk of cardiovascular disease (e.g., stroke or myocardial infarction)
- Alcoholic cardiomyopathy
- Alcoholic myopathy, with proximal muscle wasting and weakness
- Increased risk of cancer, particularly breast, mouth and throat cancer
Alcohol Abuse: Questionnaires
Alcohol dependence= chronic alcohol consumption, strong urges and cravings for alcohol, difficulty controlling consumption, tolerance and withdrawal symptoms when stopping.
Questionnaires for alcohol abuse: CAGE and AUDIT-C
CAGE Questions
The CAGE questions can be used to quickly screen for harmful alcohol use:
- C–CUT DOWN? Do you ever think you should cut down?
- A–ANNOYED? Do you get annoyed at others commenting on your drinking?
- G–GUILTY? Do you ever feel guilty about drinking?
- E–EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
AUDIT Questionnaire
TheAlcohol Use Disorders Identification Test(AUDIT) was developed by theWorld Health Organisationto screen people for harmful alcohol use. It involves 10 questions with multiple-choice answers and gives a score. A score of 8 or more indicates harmful use.
Alcohol Withdrawal
Alcohol Withdrawal
Alcohol dependence involves a risk of withdrawal symptoms. These range from mild and uncomfortable todelirium tremens. Symptoms occur at different times after alcohol consumption ceases:
- 6-12 hours: tremor, sweating, headache, craving and anxiety
- 12-24 hours:hallucinations
- 24-48 hours:seizures
- 24-72 hours:delirium tremens
Delirium Tremens
Delirium tremensis a medical emergency associated withalcohol withdrawal.****There is a 35% mortality rate if left untreated.
Alcohol is adepressantsubstance. It stimulatesGABA receptorsin the brain.GABA receptorshave a relaxing effect on the rest of the brain. Alcohol also inhibitsglutamate receptors(also known asNMDA receptors), causing a further relaxing effect on the electrical activity of the brain (glutamate is an “excitatory” neurotransmitter).
Chronic alcohol use results in theGABA systembecomingdown-regulatedand theglutamate systembecomingup-regulatedto balance the effects of alcohol. When alcohol is removed, the GABA system under-functions and the glutamate system over-functions, causing extreme excitability of the brain and excessiveadrenergic(adrenalin-related) activity. This presents with:
- Tachycardia
- Hypertension
- Arrhythmias
- Hyperthermia
- Acute confusion
- Severe agitation
- Delusions and hallucinations
- Tremor
- Ataxia (difficulties with coordinated movements)
Managing Alcohol Withdrawal
Chlordiazepoxide(Librium) is a benzodiazepine used to combat the effects of alcohol withdrawal. Diazepam is a less commonly used alternative. It is given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g., 10 – 40 mg every 1 – 4 hours). The dose is reduced over 5-7 days.
High-dose B vitamins(Pabrinex) is givenintramuscularlyorintravenously, followed by long-term oralthiamine. This is used to preventWernicke-Korsakoff syndrome.
Wernicke-Korsakoff Syndrome
Alcohol excess leads tothiamine(vitamin B1) deficiency. Thiamine is poorly absorbed in the presence of alcohol. Alcoholics often have poor diets and get many of their calories from alcohol. Thiamine deficiency leads toWernicke’s encephalopathyandKorsakoff syndrome.
Features ofWernicke’s encephalopathyinclude:
- Confusion
- Oculomotor disturbances (disturbances of eye movements)
- Ataxia (difficulties with coordinated movements)
Features ofKorsakoff syndromeinclude:
- Memory impairment (retrograde and anterograde)
- Behavioural changes
Wernicke’s encephalopathyis a medical emergency with a high mortality rate.Korsakoff syndromeis often irreversible and results in patients requiring full-time institutional care. Prevention and treatment involve thiamine supplementation and abstaining from alcohol.
