Alcoholic Hepatits Flashcards
Define alcoholic hepatitis summarising its aetiology and epidemiology
Definition: Inflammatory liver injury caused by chronic heavy intake of alcohol
Aetiology/ risk factors:
- One of the 3 forms of liver disease caused by excessive alcohol intake - the spectrum consists of:
- Alcoholic fatty liver (steatosis)
- Alcoholic hepatitis
- Chronic cirrhosis
- Histopathological features of alcohol hepatitis:
- Centrilobular ballooning (form of liver paranchymal cell death.)
- Degeneration and necrosis of hepatocytes
- Steatosis
- Neutrophilic inflammation
- Cholestasis
- Mallory-hyaline inclusions (eosinophilic intracytoplasmic aggregates of cytokeratin intermediate filaments)
- Giant mitochondria
Epidemiology: Occurs in 10-35% of heavy drinkers
Describe the history/presenting symptoms of alcoholic hepatitis
- May remain asymptomatic and undetected
- May be mild illness with symptoms such as:
- Nausea
- Malaise
- Epigastric pain
- Right hypochondrial pain
- Low-grade fever - More severe presenting symptoms include:
- Jaundice
- Abdominal discomfort or swelling
- Swollen ankles
- GI bleeding - NOTE: a long history of heavy drinking is required for the development of alcoholic hepatitis (around 15-20 years)
- There may be events that trigger the disease (e.g. aspiration pneumonia, injury)
What are the signs of Alcoholic hepatitis upon physical examination?
Signs of Alcohol Excess:
- Malnourished
- Palmar erythema
- Dupuytren’s contracture
- Facial telangiectasia
- Parotid enlargement
- Spider naevi
- Gynaecomastia
- Testicular atrophy
- Hepatomegaly
- Easy bruising
Signs of Severe Alcoholic Hepatitis:
- Febrile (in 50% of patients)
- Tachycardia
- Jaundice
- Bruising
- Encephalopathy (e.g. liver flap, drowsiness, disorientation)
- Ascites
- Hepatomegaly
- Splenomegaly
What investigations are used to identify alcoholic hepatitis?
- Bloods
o FBC:
•Low Hb
•High MCV
•High WCC
•Low platelets
o LFTs:
•High AST + ALT
•High bilirubin
•High ALP + GGT
•Low albumin
o U&Es:
•Urea and K+ tend to be low
o Clotting: prolonged PT is a sensitive marker for significant liver damage
- Ultrasound: check for other causes of liver impairment (e.g. malignancy)
- Upper GI Endoscopy: investigate varices
- Liver Biopsy: can help distinguish from other causes of hepatitis
- EEG-slow-wave activity indicates encephalopathy
How is alcoholic hepatitis managed?
•Acute:
- Thiamine
- Vitamin C and other multivitamins (can be given as Pabrinex)
- Monitor and correct K+, Mg2+ and glucose
- Ensure adequate urine output- Treat encephalopathy with oral lactulose or phosphate enemas
- Ascites - manage with diuretics (spironolactone with/without furosemide)
- Therapeutic paracentesis
- Glypressin and N-acetylcysteine for hepatorenal syndrome
•Nutrition
- Via oral or NG feeding is important - Protein restriction should be avoided unless the patient is encephalopathic - Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally
•Steroid Therapy -reduce short-term mortality for severe alcoholic hepatitis
NOTE: hepatorenal syndrome - the development of renal failure in patients with advanced chronic liver disease
•Thought to arise because of abnormalities in blood vessel tone in the kidneys
* Blood vessels in the kidney constrict because of the dilatation of blood vessels in the splanchnic circulation (supplying the intestines), which is mediated by factors released by the kidneys * The splanchnic vasodilation leads to reduced effective volume of blood detected by the juxtaglomarular apparatus, leading to activation of the RAS and vasoconstriction of vessels in the kidney * This leads to kidney failure
What are the complications of alcoholic hepatitis?
- Acute liver decompensation - Hepatorenal syndrome
- Cirrhosis
Summarise the prognosis for patients with Alcoholic hepatitis
•Mortality:
- First month = 10%
- First year = 40%
•If alcohol intake continues, most will progress to cirrhosis within 1-3 years
