Alcoholic hepatitis, Chronic alcoholism and Wernicke's and Korsakoff Flashcards
when to give prednisolone?
in severe alcohol hepatitis when discriminant function is >32
give 32 mg of methylprednisolone or 40 mg of prednisolone
prednisone needs first pass metabolism with liver before becoming active which is why prefer prednisolone
Alcoholic hepatitis pts history will include
>20 years of excessive ETOH use may increase intake acutely in response to stressful situations
presentation of alcoholic hepatitis
acute jaundice
fever
anorexia
RUQ epigastric pain
abdominal distension to ascites
can see muscle wasting and proximal muscle weakness
labs seen on alcoholic hepatitis:
AST/ALT ratio >2
ALT<300
elevated GGT and INR sometimes
ferritin can be elevated >1000
Abdominal imaging shows fatty liver
what can we see with liver in alcoholic hepatitis?
Can see elevated iron in liver but it’s not hereditary hemochromatosis b/c HH will have much higher iron in serum and transferrin saturation is >50% Also no AST/ALT ratio >2
AMS and ataxia.
electrolyte disturbances (hyponatremia), hypoglycemia, anion gap metabolic acidosis with ketones in urine
Wernicke’s encephalopathy - see this with thiamine deficiency
triad of ataxia, encephalopathy, oculomotor dysfunction (nystagmus, gaze palsies) although don’t need to have all 3
associated with longstanding alcoholism but can be seen with chronic malnourishment (anorexia nervosa), hyperemesis gravidarum, and post bariatric surgery
need to give thiamine with glucose
magnesium deficiency causes
hypokalemia, vertical nystagmus
severe deficiency can cause hypocalemia and in_voluntary movements, seizures and arrhythmias_. No gaze palsies
Refeeding syndrome happens in
chronically malnourished pt and causes hypokalemia
causes severe hypophosphatemia - see CHF, edema, seizures, and rhabdomyolysis.
No gaze palsies.
steroids are contraindicate for alcoholic hepatitis if there is:
concomitant pancreatitis, active infection (hep B and C) and GI bleed or renal failure
give pentoxifylline or TNF-synthesis inhibitor instead of steroids.
Lille score is used to calculate
done at 7 days of hospitalization with someone who has alcoholic hepatitis who has been on steroids for DF>32
meant to help clarify if pt is responsing to steroids.
incorporates age, bilirubin, serum albumin, prothrombin time, and change in bilirubin on day seven from day 1.
Lille Score >0.45 - not responding to steroids.
how do we follow a pt’s Maddrey’s discriminant function?
give prednisolone 40 mg daily for one week.
then calculate a Lille score on day 7 or repeat Maddrey’s discriminant function.
If Lille score is <0.45 then responds to steroids and good prognosis (>85% survival in the next 6 months)
In pts who respond, continue steroids for 28 days followed by a 16 day taper. if no response, stop steroids.
excessive alcohol is defined as:
>15-21 drinks/week for men
>10-14 drinks in women
see macrocytosis and AST/ALT ratio >2
