Alcoholic Hepatits

Question 1

Define Alcoholic Hepatitis?

Answer 1

Inflammatory liver injury caused by chronic heavy intake of alcohol

Question 2

What is the aetiology of Alcoholic Hepatitis?

Answer 2

One of the three forms of liver disease caused by excessive alcohol intake - the spectrum consists of:

• Alcoholic fatty liver (steatosis)
• Alcoholic Hepatitis
• Chronic cirrhosis

Question 3

What are the histopathological features of Alcoholic Hepatitis?

Answer 3

Centrilobular ballooning 
Degeneration and necrosis of hepatocytes 
Steatosis 
Neutrophilic Inflammation
Cholestasis
Mallory-hyaline inclusions
Giant mitochondria

Question 4

What are Mallory-hyaline inclusions?

Answer 4

Eosinophilic intracytoplasmic aggregates of cytokeratin intermediate filaments

Question 5

What is the epidemiology of Alcoholic Hepatitis?

Answer 5

Occurs in 10-35% of heavy drinkers

Question 6

What are the presenting symptoms of Alcoholic Hepatitis?

Answer 6

May remain asymptomatic and undetected
May be mild illness with symptoms
More severe presenting symptoms

Question 7

What are some of the symptoms of mild illness of Alcoholic Hepatitis?

Answer 7

Nausea
Malaise 
Epigastric Pain
Right hypochondral pain
Low-grade fever

Question 8

What are some of the symptoms of more severe illness for Alcoholic Hepatitis?

Answer 8

Jaundice
Abdominal discomfort or swelling
Swollen Ankles
GI bleeding

Question 9

What history is needed for Alcoholic Hepatitis?

Answer 9

A long history of heavy drinking is required for the development of Alcoholic Hepatitis (around 15-20 years)

Question 10

What can trigger Alcoholic Hepatitis?

Answer 10

Certain Events

For example: aspiration pneumonia, injury

Question 11

What are the signs of Alcoholic Hepatitis on physical examination?

Answer 11

Signs of Alcohol Excess

Signs of Severe Alcoholic Hepatitis

Question 12

What are the Signs of Alcohol Excess?

Answer 12

Malnourished 
Palmar Erythema
Dupuytren's Contracture 
Facial Telangiectasia
Parotid Enlargement 
Spider naevi 
Gynaecomastia 
Testicular atrophy 
Hepatomegaly
Easy brusing

Question 13

What are the signs of Severe Alcoholic Hepatitis?

Answer 13

Febrile (in 50% of patients)
Tachycardia
Jaundice 
Bruising 
Signs of Encephalopathy
Ascites 
Hepatomegaly
Splenomegaly

Question 14

What are some of the signs of Encephalopathy?

Answer 14

e.g.
Liver Flap
Drowsiness
Disorientation

Question 15

What bloods would you do for Alcoholic Hepatitis?

Answer 15

FBC
LFTs
U&Es
Clotting

Question 16

What would you look for specifically on a FBC for Alcoholic Hepatitis?

Answer 16

Low Hb
High MCV
High WCC
Low platelets

Question 17

What would you look for specifically on LFTs for Alcoholic Hepatitis?

Answer 17

High AST + ALT
High bilirubin
High ALP + GGT
Low albumin

Question 18

What would you look for on U&Es for Alcoholic Hepatitis?

Answer 18

Urea and K+ tend to be low

Question 19

What would you look for Clotting for Alcoholic Hepatitis?

Answer 19

Prolonged PT is a sensitive maker for significant liver damage

Question 20

Why would we do a US for Alcoholic Hepatitis?

Answer 20

Check for other causes of liver impairment (e.g. malignancy)

Question 21

Why would we do an Upper GI Endoscopy for Alcoholic Hepatitis?

Answer 21

Investigate varices

Question 22

Why would we do a Liver Biopsy for Alcoholic Hepatitis?

Answer 22

Can help distinguish from other causes of hepatitis

Question 23

What might you see on an EEG for Alcoholic Hepatitis?

Answer 23

Slow-wave activity indicates encephalopathy

Question 24

What is the acute management plan for Alcoholic Hepatitis?

Answer 24

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

Question 25

What nutritional management plan for Alcoholic Hepatitis?

Answer 25

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

Question 26

How can we use Steroid Therapy for Alcoholic Hepatitis?

Answer 26

Reduce short-term mortality for severe alcoholic hepatitis

Question 27

What is Hepatorenal Syndrome?

Answer 27

The development of renal failure in patients with advanced chronic liver disease

Question 28

What is the aetiology of Hepatorenal Syndrome?

Answer 28

Thought to be 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

Question 29

What are the possible complications of Alcoholic Hepatitis?

Answer 29

Acute Liver Decompensation
Hepatorenal Syndrome
Cirrhosis

Question 30

What is the prognosis for patients with Alcoholic Hepatitis?

Answer 30

Mortality:
First month = 10%
First Year = 40%

If alcohol intake continues, most will progress to cirrhosis within 1-3 years