alcoholic hepatitis Flashcards
definition of alcoholic hepatitis
inflammatory liver injury caused by chronic heavy intake of alcohol
aetiology of alcoholic hepatitis
specturm from alcoholic fatty liver (steatosis) to alocholic hepatitis and chronic cirrhosis
in alcoholic hepatitis the liver histopathology shows:
- centrilobular ballooning degeneration
- necrosis of hepatocyutes
- steatosis
- neutrophilic infammation
- cholestasis
- Mallory hyaline inclusions (eosinophilic intracytoplasmic aggregates of cytokine intermediate filaments)
- giant mitochondria
epidemiology of alcoholic hepatitis
10-35% of heavy drinkers develop alc hep
sx of alcoholic hepatitis
may be asymptomatic
mild illness - nausea, malaise, epigastric or R hypochondrial pain, low grade fever
anorexia
D and V
jaundice
abdo discomfort or swelling
swollen ankles or GI bleeding
women present with more florid illness than men
hx of heavy alcohol intake - 15-20yrs of excessive intake necessary for development of alcoholic hep
may be trigger events eg aspiration pneumonia or injury
signs of alcohol excess in alcoholic hepatitis
malnourished
palmar erythema
dupuytren’s contracture
facial telangiectasia
parotid enlargement
spider naevi
gynaecomastia
testicular atrophy
tender hepatomegaly
easy bruising
signs of severe alcoholic hepatitis
febrile - 50% pts
tachycardia
high RR
jaundice >50%
brusiing
encephalopathy - hepatic foetor, asterixis, drowsiness, unable to copy a 5 pointed star, disorientated
ascites - 30-60% of pts
hepatomegaly - usually mild-moderately enlarged and may be tender
splenomegaly
bleeding - coagulopathy
Ix for alcoholic hepatitis
bloods
US - for other causes of liver impairment eg malignancy
upper GI endoscopy - look for varices
liver biopsy - percutaneous or transjugular (in the presence of coagulopathy) may be helpful to distinguish from other causes of hepatitis
electroencephalogram - for slow-wave activity indicative of encephalopathy
bloods for alcoholic hepatitis
FBC
- low Hb, plts
- high MCV, WCC
LFT
- high transaminases, BR, ALP, GGT
- low albumin
UE - urea and creatinine levels - low (unless significant renal impairment)
clotting - high PT/INR
acute mx of alcoholic hepatitis
thiamine - hgigh dose B vitamins can be given as Pabrinex
Vit C and other multivitamins (vit K)- initially parenterally
monitor and correct K+, Mg2+ and glucose abnormalities
ensure adequate UO
CVP monitoring
treat encephalopathy with oral lactulose and phosphate enemas
ascites - diuretcis - spirinolactone with or w/o frusemide, or therapeutic paracentesis
glypression and N-acetylcysteine for hepatorenal syndrome
screen for infections +- ascitic tap and treat for SBP
stop alcohol - chlordiazepoxide for withdrawal, or IM lorazepam
daily weight, LFT, UE, INR
nutrition for alcoholic hepatitis
nutritional support with oral or nasogastric feeding is important with increased caloric intake
protein restriction should be avoided unless the pt is encephalopathic - protein prevents encephalopathy, sepsis and some deaths
total enteral nutrition considered - improves mortality
nutritional supplementation and vitamins (B group, thiamine, folic acid) - start parenterally then continue orally after
steroid therapy for alcoholic hepatitis
reduce short-term mortality for severe alcoholic hep
if Maddrey’s discriminant function >31 and encephalopathy - consider prednisolone
CI
- sepsis
- variceal bleeding
complications of alcoholic hepatitis
acute liver decompensation
hepatorenal syndrome - renal failure secondary to advanced liver disease
cirrhosis
prognosis of alcoholic hepatitis
mortality in 1st mo is 10%, 40% in 1st yr
if alcohol intake intake continues - most progress to cirrhosis in 1-3yrs
Maddrey’s discriminant function:
- MDF = (bilirubin/17) + prolongation of PT x 4:6)
- If MDF > 32, this indicates >50% 30-day mortality
glasgow alcoholic hepatitis score (GAHS): If GAHS >= 9 from Day 1 to 9, this indicates >50% 30-day mortality.
