Alcoholic Hepatitis

Question 1

What is alcoholic hepatitis caused by?

Answer 1

it is a very common cause of liver injury that is caused by excessive alcohol intake

Question 2

What feature is associated with alcoholic hepatitis that is not very specific for predicting if the liver will develop cirrhosis?

Answer 2

typically there will be steatosis of the liver

this is a pathological change in which fat globules begin to accumulate in the cytoplasm of liver cells

it can be quite harmless, so is not very specific for predicting if the liver will develop cirrhosis

Question 3

What is Mallory’s hyalin?

What does it suggest if it is present?

Answer 3

it is an aggregate of filament found in the hepatocytes that, if present, indicates a risk of irreversible changes in hepatocytes that may ultimately lead to cirrhosis

Question 4

What is Mallory’s hyalin a sign of?

Answer 4

Mallory’s hyalin (aka Mallory bodies) are not specific for alcoholic liver disease, but is a sign of steatohepatitis

Question 5

How is alcohol broken down by the liver?

Answer 5

• ethanol is oxidised to acetaldehyde
• acetaldehyde is the converted to acetate by the mitochondria of liver cells
• acetate is released into the bloodstream and taken up by peripheral tissues
• in peripheral tissues it is metabolised to carbon dioxide, fatty acids and water

Question 6

Why do some people believe that the gastric mucosa itself is responsible for a lot of alcohol metabolism?

Answer 6

alcohol dehydrogenases are present in many tissues around the body

Question 7

Why do a lot of alcoholics not lose weight despite severe malnutrition?

Answer 7

alcoholic drinks contain a lot of sugar and calories

Question 8

What is a cogener?

What types of effects of alcohol do they cause?

Answer 8

• long-term effects of alcohol are all due to ethanol
• the short term effects are often due to other alcohols present in the drink, such as isoamyl alcohol
• these additional alcohols are known as cogeners

Question 9

What % of heavy drinkers will develop cirrhosis and fatty liver?

Answer 9

• 10 - 30% of heavy drinkers will develop cirrhosis
• 50% of heavy drinkers will have fatty liver

Question 10

What nutritional factors are thought to contribute to liver damage?

Answer 10

nutritional factors are controversial, although it is possible that malnutrition and obesity both contribute to liver damage

Question 11

What factor alongside alcohol consumption increases the risk of hepatitis?

Answer 11

high alcohol consumption combined with hepatitis C infection greatly increases the risk of hepatitis

Question 12

What is the first sign of alcoholic liver disease?

How can this be changed if drinking is stopped?

Answer 12

the first sign is fatty liver

this occurs in most heavy drinkers at some time, but it is completely reversible upon cessation of alcohol

Question 13

How is fat metabolism changed during excessive alcohol consumption?

Why does this occur?

Answer 13

• hepatocytes have to divert resources away from metabolising fats to metabolising alcohol
• fat metabolism is altered resulting in fat deposits inside the cells
• more fats are released into the blood stream as fatty acids
• there is increased synthesis of triglycerides and fatty acids

Question 14

How can acetaldehyde cause damage to the liver?

Answer 14

it binds to liver cell proteins and causes injury to the hepatocytes that leads to inflammation

this inflammation can be a causatory factor in cirrhosis and is likely to cause Mallory’s sign

Question 15

How can alcohol affect collagen synthesis and what can this ultimately lead to?

Answer 15

• alcohol stimulates collagen synthesis by fibroblasts as well as fibroblast proliferation
• the fibrosing process ends up linking hepatic veins to portal veins
• in these places, cell regeneration occurs and nodules form
• this is the start of the process of cirrhosis

Question 16

What is shown in this image?

Answer 16

Mallory body

these are eosinophilic inclusions that have a “rope-like” appearance

Question 17

What are the clinical signs of alcoholic hepatitis that are related to malnutrition?

Answer 17

• very thin arms and legs (due to muscle wasting)
• swollen abdomen
• red tongue (iron-deficiency anaemia)
• dry scaly and cracked skin (due to zinc / fatty acid deficiency)

Question 18

What are the clinical signs of alcoholic hepatitis relating to the endocrine system?

Answer 18

• gynaecomastia
• testicular atrophy
• loss of body hair
• signs of “pseudo-Cushing’s” - red face, hump, striae

Question 19

What are signs of alcohol hepatitis relating to the face/skin?

Answer 19

• parotid enlargement
• spider naevi
• easy bruising
• Dupuytren’s contracture

Question 20

What are neuromuscular signs of alcoholic liver disease?

Answer 20

• tremor
• memory loss / cognitive impairment
• peripheral myopathy (degradation of muscle)
• epilepsy
• Wernicke-Korskoff syndrome

Question 21

What are the cardiovascular clinical features of alcoholic liver disease?

Answer 21

• hypertension
• cardiomyopathy (disease of the heart muscle)
• hyperdynamic circulation (abnormally increased circulatory volume)

Question 22

What are the clinical features of alcoholic liver disease affecting the bones?

Answer 22

• rib fractures may be seen on CXR
• spinal osteoporosis (particularly in men)

Question 23

Generally what are the signs of fatty liver?

How does this differ from alcoholic hepatitis?

Answer 23

patients with fatty liver generally have few symptoms

they may notice nausea and malaise and LFTs may be slightly unusual

mild alcoholic hepatitis may be indistinguishable from fatty liver disease (often the 2 co-exist)

Question 24

What are the symptoms of mild alcoholic hepatitis?

Answer 24

they tend to be more severe than fatty liver:

• anorexia
• nausea
• abdominal pain
• weight loss

Question 25

What might be present on examination in someone with fatty liver?

Answer 25

they tend to be asymptomatic but hepatomegaly may be present on examination

Question 26

What do laboratory tests usually show in fatty liver?

Answer 26

• laboratory tests are usually normal
• elevated mean corpuscular volume (MCV) often indicates heavy drinking
  
  • this is the average volume of a RBC
• the y-glutamyltansferase (y-GT) level is usually elevated
  
  • this indicates that the enzyme is leaking out of hepatocytes and into the blood, suggesting damage to the liver

Question 27

What actually is alcoholic hepatitis?

What is happening within the liver?

Answer 27

necrosis of liver cells and infiltration of polymorphonuclear leucocytes

with accumulation of dense cytoplasmic material (called a Mallory body) in hepatocytes

it may progress to cirrhosis, particularly with continued alcohol consumption

Question 28

What will LFTs and other blood tests show in alcoholic hepatitis?

Answer 28

investigations show leucocytosis with elevated bilirubin and transferases

• AST and ALT are usually < 500 IU/L
  
  • higher values suggest hepatitis due to another cause
• albumin may be low
• prothrombin time may be prolonged

Question 29

What is the treatment for alcoholic hepatitis?

Answer 29

• treatment is supportive and adequate nutritional intake must be maintained
• corticosteroids are of benefit in severe disease

Question 30

What is alcoholic cirrhosis?

Answer 30

• this is the final stage of liver disease from alcohol abuse
• there is destruction and fibrosis, with regenerating nodules producing a classic micronodular cirrhosis
• there are usually signs of chronic liver disease