Alcoholic Hepatitis Flashcards
Define
Inflammatory liver injury caused by chronic heavy intake of alcohol
- 80% progress to cirrhosis
Causes
Heavy alcohol intake
~15-20 years excessive intake necessary
One of the THREE forms of liver disease caused by excessive alcohol intake - the spectrum consists of:
- Alcoholic fatty liver (steatosis)
- Alcoholic hepatitis
- Chronic cirrhosis
Histopathological features of alcohol hepatitis:
- Centrilobular ballooning
- Degeneration and necrosis of hepatocytes
- Steatosis
- Neutrophilic inflammation
- Cholestasis
- Mallory-hyaline inclusions (eosinophilic intracytoplasmic aggregates of cytokeratin intermediate filaments)
- Giant mitochondria
Epidemiology
Occurs in 10-35% of heavy drinkers
Symptoms
- May remain asymptomatic and undetected
- May be mild illness with symptoms such as:
- Nausea
- Malaise
- Epigastric pain
- Right hypochondrial pain
- Low-grade fever
- 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)
Signs
Signs of Alcohol Excess
- Malnourished
- Palmar erythema
- Dupuytren’s contracture
- Facial telangiectasia
- Parotid enlargement
- Spider naevi
- Gynaecomastia
- Testicular atrophy
- Hepatomegaly
- Easy bruising
Signs of Severe Alcoholic Hepatitis
- Febrile (in 50% of patients)
- Tachycardia
- Jaundice
- Bruising
- Encephalopathy (e.g. liver flap, drowsiness, disorientation)
- Ascites
- Hepatomegaly
- Splenomegaly
Investigations
Bloods
FBC:
- Low Hb
- High MCV
- High WCC
- Low platelets
LFTs:
- High AST + ALT
- High bilirubin
- High ALP + GGT
- Low albumin
U&Es:
- Urea and K+ tend to be low
Clotting: prolonged PT is a sensitive marker for significant liver damage
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
Management
Acute
- Thiamine, Vitamin C and other multivitamins (can be given as Pabrinex)
- Monitor and correct K+, Mg2+ and glucose
- Ensure adequate urine output
- Treat encephalopathy with oral lactulose or phosphate enemas
- Ascites - manage with diuretics (spironolactone with/without furosemide)
- Hepatorenal syndrome with Glypressin and N-acetylcysteine
Nutrition
- Via oral or NG feeding is important : increase caloric intake
- Protein restriction should be avoided unless the patient is encephalopathic
- 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
Long-term: sort out alcohol dependence
Complications
Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
Prognosis
Mortality:
- First month = 10%
- First year = 40%
If alcohol intake continues, most will progress to cirrhosis within 1-3 years
