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 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?
- 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)
- cholecystitis
- hepatic vein thrombosis
- acute liver failure
- haemochromatosis
- Wilson’s disease
- drug/toxin-induced hepatitis
- autoimmune hepatitis (ANA, ASMA, anti-LKM)
- Wernicke’s encephalopathy
- biliary obstruction
