Alcoholic Hepatitis

Question 1

Definition

Answer 1

Inflammatory liver injury caused by chronic heavy intake of alcohol

Question 2

Aetiology/Risk factors

Answer 2

One of the THREE forms of liver disease caused by excessive alcohol intake - the spectrum consists of:

o Alcoholic fatty liver (steatosis)
o Alcoholic hepatitis
o Chronic cirrhosis

Question 3

Histopathological features

Answer 3

Histopathological features of alcohol hepatitis:

o Centrilobular ballooning
o Degeneration and necrosis of hepatocytes
o Steatosis
o Neutrophilic inflammation
o Cholestasis
o Mallory-hyaline inclusions (eosinophilic intracytoplasmic aggregates of cytokeratin intermediate filaments)
o Giant mitochondria

Question 4

Epidemiology

Answer 4

Occurs in 10-35% of heavy drinkers

Question 5

Presenting symptoms (mild)

Answer 5

· May remain asymptomatic and undetected

· May be mild illness with symptoms such as:
o Nausea
o Malaise
o Epigastric pain
o Right hypochondrial pain
o Low-grade fever

Question 6

Presenting symptoms (severe)

Answer 6

· More severe presenting symptoms include:
o Jaundice
o Abdominal discomfort or swelling
o Swollen ankles
o 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 7

Signs on physical examination (alcohol excess)

Answer 7

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

Question 8

Signs on physical examination (alcoholic hepatitis)

Answer 8

o Febrile (in 50% of patients)
o Tachycardia
o Jaundice
o Bruising
o Encephalopathy (e.g. liver flap, drowsiness, disorientation)
o Ascites
o Hepatomegaly
o Splenomegaly

Question 9

Investigations (bloods)

Answer 9

o FBC:
· Low Hb
· High MCV
· High WCC
· Low platelets

o LFTs:
· High AST + ALT
· High bilirubin
· High ALP + GGT
· Low albumin

o U&Es:
· Urea and K+ tend to be low

o Clotting: prolonged PT is a sensitive marker for significant liver damage

Question 10

Investigation (other)

Answer 10

· Ultrasound - check for other causes of liver impairment (e.g. malignancy)

· Upper GI Endoscopy - investigate varices

· Liver Biopsy - can help distinguish from other causes of hepatitis

· EEG - slow-wave activity indicates encephalopathy

Question 11

Management plan (acute)

Answer 11

o Thiamine

o Vitamin C and other multivitamins (can be given as Pabrinex)

o Monitor and correct K+, Mg2+ and glucose

o Ensure adequate urine output

o Treat encephalopathy with oral lactulose or phosphate enemas

o Ascites - manage with diuretics (spironolactone with/without furosemide)

o Therapeutic paracentesis

o Glypressin and N-acetylcysteine for hepatorenal syndrome

Question 12

Management plan (nutrition and steroid therapy)

Answer 12

· Nutrition
o Via oral or NG feeding is important
o Protein restriction should be avoided unless the patient is encephalopathic
o Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally

· Steroid Therapy - reduce short-term mortality for severe alcoholic hepatitis

Question 13

Possible complications

Answer 13

· Acute liver decompensation

· Hepatorenal syndrome

· Cirrhosis

Question 14

Hepatorenal Syndrome

Answer 14

hepatorenal syndrome - the development of renal failure in patients with 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 the kidneys

· 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 15

Prognosis

Answer 15

· Mortality:
o First month = 10%
o First year = 40%

· If alcohol intake continues, most will progress to cirrhosis within 1-3 years