Alcoholic Hepatitis

Question 1

3 stages of alcoholic liver disease

Answer 1

Alcoholic steatosis
Alcoholic hepatitis
Alcoholic cirrhosis

Question 2

Who is especially susceptible to the adverse effects of alcohol?

Answer 2

Women

Question 3

Alcoholic steatosis

Answer 3

NADH produced, inhibit gluconeogenesis
B-oxidation and TG production
Increased hepatic uptake of fats and accumulation of lipids in hepatocytes
Some peri-venular fibrosis

Question 4

Macroscopic appearance of alcoholic steatosis

Answer 4

Large, soft, yellow

Question 5

Alcoholic steatosis: reversible or irreversible?

Answer 5

Reversible with abstinence?

Question 6

Alcoholic hepatitis

Answer 6

Accumulation of acetylaldehyde (hepatotoxic)
Induction of CYP450 and increased metabolism leads to accumulation of free radicals
Direct effects of alcohol

Question 7

Histological findings in alcoholic steatohepatitis

Answer 7

Macrovesicular steatosis
Hepatocyte swelling and necrosis
Mallory bodies
Pericellular fibrosis and fibrosis around central vein with sclerosing hyaline necrosis
Inflammatory cells (esp neutrophils)

Question 8

Macroscopic appearance of alcoholic hepatitis

Answer 8

Liver mottled-red with bile-stained areas

Normal or hepatomegaly

Question 9

Symptoms of ALD

Answer 9

Non-specific: fever, malaise, weight loss, abdo pain, N+V, diarrhoea
Features of hepatic dysfunction: hepatic encephalopathy, ascites, jaundice, leuconychia
Features of portal HTN: oesophageal varices, caput medusae, haemorrhoids

Question 10

Portosystemic anastamoses

Answer 10

Oesophageal
Umbilical
Rectum
Retroperitoneal
Intrahepatic

Question 11

Difference between ASH and NASH

Answer 11

Morphology identical but in non-drinkers

More common in women

Question 12

Causes of NASH

Answer 12

Obesity
DM
Drugs (e.g. amiodarone, iron)
Pregnancy
Rapid weight loss
Starvation
Malabsorption
Inherited metabolic disorders (e.g. FA oxidation defects)

Question 13

Investigations for ALD

Answer 13

FBE: increased WCC (hepatitis-related leukaemoid reaction or associated infection), macrocytic anaemia, thrombocytopaenia
Alcohol screen
LFTs: raised serum aminotransferases (AST/ALT >2), ALP, GGT (more sensitive), bilirubin, albumin
UEC: decreased Na+, K+, PO4-, Mg2+ with advanced cirrhosis, increased urea if active GI bleed, increased urea and creatinine if hepatorenal syndrome
Coags: elevated PT/INR
Abdo U/S: hepatomegaly, fatty liver, liver cirrhosis, liver mass, splenomegaly, ascites, evidence of portal hypertension, HCC monitoring every 6-12 months
Liver biopsy (most sensitive and specific)
FOR DDx: iron studies, autoAbs, viral serology

Question 14

Management of ALD

Answer 14

Abstain from alcohol (may need sedatives)
High dose B vitamins
Treat complications (e.g. vitamin K, fluid/Na+ restriction, frusemide)
Corticosteroids if severe hepatitis +/- encephalopathy
Pentoxifylline (xanthine; PDE, a2 antagonist, reduces blood viscosity)
Ensure pt up to date with vaccinations
Liver transplantation if requirements met

Question 15

Maddrey score

Answer 15

4.6 x (PT – Control PT ) + bilirubin

Give steroids if >32

Question 16

Causes of death from ALD

Answer 16

Hepatic coma
GIT haemorrhage
Intercurrent infection
Hepatorenal syndrome
HCC

Question 17

Prescription medications causing hepatitis

Answer 17

Abx
Antidepressants (tricyclics)
Antiepileptics
Anaesthetic agents
Statins
Immunosuppressants
NSAIDs
Salicylate (Reyes)