Alcoholic hepatitis (GI) Flashcards
When does alcoholic hepatitis develop?
Due to sustained long-term alcohol consumption in 10-35% of heavy drinkers
What is required for the development of alcoholic hepatitis?
Long history of heavy drinking for 10-12 years (40-80g/day in men, 20-40g/day in women)
What are the three stages of liver damage in alcohol-related liver disease?
- fatty liver (steatosis) - liver large, heavy, greasy, tender with increased fat production but no Sx
- alcohol-related hepatitis (inflammation and necrosis) - production of ROS, acetaldehyde
- alcohol-related cirrhosis - as hepatocytes die, scar tissue forms (including peri-venular fibrosis)
What are the clinical features of alcoholic hepatitis? (10)
- abdominal pain (RUQ)
- jaundice
- anorexia + weight loss
- N&V
- fatigue
- malnutrition
- muscle wasting
- confusion
- fever with tachycardia
- pruritus
What might you see on examination in alcoholic hepatitis? (12)
- hepatomegaly (may also be a sign of hepatocellular carcinoma)
- splenomegaly (severe)
- ascites (–> weight gain)
- jaundice
- haematemesis and melaena
- venous collaterals
- hepatic mass
- palmar erythema
- cutaneous telangiectasia
- asterixis
- clubbing
- Dupuytren’s contracture
What would you see on examination in severe alcoholic hepatitis? (2)
Ascites and splenomegaly due to portal hypertension
What are some risk factors for alcoholic hepatitis? (8)
- alcohol
- hepatitis C (worse prognosis, higher incidence of hepatocellular carcinoma)
- female (can develop with lower drinking levels)
- smoking (increases progression of fibrosis)
- obesity
- age>65
- Hispanic ethnicity
- genetic polymorphisms
What are the first-line investigations for alcoholic hepatitis? (1 + 6)
LFTs:
- serum aspartate aminotransferase (AST), alanine aminotransferase (ALT)
- serum AST/ALT ratio
- serum alkaline phosphatase (ALP)
- serum bilirubin
- serum albumin
- serum gamma glutamyl transferase (GGT)
What do LFTs show in alcoholic hepatitis? (6)
- raised AST (men>30, women>19)
- raised ALT (men>30, women>19)
- raised ALP (if associated cholestasis)
- raised BR
- low albumin
- raised GGT
What is the AST/ALT ratio in alcoholic hepatitis?
Ratio AST:ALT >2 (2:1)
If ALT>AST, this suggests concomitant presence of viral hepatitis or possibly NAFLD
What does FBC show in alcoholic hepatitis?
- non-megaloblastic macrocytic anaemia (sign of alcoholic liver disease) - due to iron deficiency/GI bleed/folate deficiency/haemolysis/hypersplenism
- thrombocytopenia (due to alcohol-induced BM suppression, folate deficiency or hypersplenism)
- leukocytosis
- high MCV
What does prothrombin time show in alcoholic hepatitis?
Increased PT - sensitive marker of significant liver damage
Clotting factors 2,7,9,10 made by liver
What might U&Es show in alcoholic hepatitis? (2)
- elevated urea in presence of normal creatinine = active GI bleeding
- elevated U&E = hepatorenal syndrome
What scan is done in alcoholic hepatitis?
Hepatic US
- check for other causes of liver impairment e.g. malignancy (screen for HCC every 6-12m in ALD patients with cirrhosis –> CT/MRI if mass found)
- hepatomegaly, fatty liver, liver cirrhosis, mass, splenomegaly, ascites, portal HTN evidence
- transient elastography: US-based technique for detecting hepatic fibrosis without need for liver biopsy
- liver biopsy can also be done
What are some differential diagnoses for alcoholic hepatitis? (12)
- hepatitis A (anti-HepA IgM antibody)
- hepatitis B (HBsAg, HepB DNA or anti-HBcAg IgM, ALT>AST)
- hepatitis C (chronic alcohol, HepC RNA or anti-HepC, ALT>AST)
- drug/toxin-induced hepatitis
- autoimmune hepatitis (ANA, ASMA, anti-LKM)
- cholecystitis
- hepatic vein thrombosis
- acute liver failure
- haemochromatosis
- Wilson’s disease
- Wernicke’s encephalopathy
- biliary obstruction
What scoring systems are used in alcoholic hepatitis? (4)
- MDF (Maddrey’s discriminant function) - PT and total BR
- MELD - creatinine, serum BR and INR
- Glasgow Alcoholic Hepatitis Score (GAHS) - based on composite scoring of age, serum urea, serum BR, PT and WBC count
- Child-Pugh score: BR, albumin, PT, ascites, encephalopathy
What is key in managing alcoholic hepatitis?
Alcohol abstinence + management of alcohol withdrawal
- withdrawal: chlordiazepoxide
- benzodiazepines (high doses may trigger/worsen hepatic encephalopathy)
- long-acting e.g. diazepam = protect against seizures and delirium
- short-acting e.g. lorazepam safer in older adults and those with hepatic dysfunction
What is the acute management for alcoholic hepatitis?
Pabrinex as it contains:
- thiamine (vitamin B1) to prevent Wernicke’s encephalopathy
- vitamin C
What steroid therapy is given in alcoholic hepatitis, when and why?
- prednisolone
- MDF score 32+ or hepatic encephalopathy
- Maddrey’s discriminant function (MDF) calculated using PT and [BR]
- reduces short-term mortality for severe alcoholic hepatitis
- avoid in patients with: GI bleeding requiring transfusion, active infection, hepatorenal syndrome
Why do we advise sodium restriction and diuretics in alcoholic hepatitis?
- furosemide + spironolactone
- to induce sufficient sodium excretion into urine
- given to patients with ascites
What is the treatment for end-stage alcoholic hepatitis?
- liver transplant
- priority based on MELD score (composite scoring of serum creatinine, serum BR and INR)
What are some complications of alcoholic hepatitis? (9)
- cirrhosis
- hepatic encephalopathy
- portal hypertension
- GI bleeding
- coagulopathy
- renal failure
- hepatorenal syndrome
- hepatocellular carcinoma
- sepsis
Describe the prognosis of alcoholic hepatitis.
- 10% mortality in first month
- 40% mortality in first year
- if alcoholic intake continues, will progress to cirrhosis in 1-3 years