Alcoholic Liver Disease Flashcards
What is the stepwise progression of alcoholic liver disease
- Alcohol related fatty liver: build-up of fat in the liver (reversible)
- Alcoholic hepatitis: Inflammation (usually reversible)
- Cirrhosis: scar tissue (irreversible)
What is the current recommended alcohol consumption?
No more than 14 units per week for both men and women
List 2 questionnaires which can be used to screen for harmful alcohol us
- CAGE Questions
- AUDIT Questionnaire
Explain the CAGE questionnaire
C – CUT DOWN? Ever thought you should?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Ever feel guilty about drinking?
E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?
List 4 complications of alcohol
- Alcoholic Liver Disease
- Cirrhosis and the complications ie. hepatocellular carcinoma
- Alcohol Dependence and Withdrawal
- Wernicke-Korsakoff Syndrome
- Pancreatitis
- Alcoholic Cardiomyopathy
List 4 signs of liver disease
- Jaundice
- Hepatomegaly
- Spider Naevi
- Palmar Erythema
- Gynaecomastia
- Bruising – due to abnormal clotting
- Ascites
- Caput Medusae – engorged superficial epigastric veins
- Asterixis – “flapping tremor” in decompensated liver disease
What Investigations would you do for Liver Failure
- Bloods
- Ultrasound
- Endoscopy
- CT and MRI scans
- Liver Biopsy
What would you look for in bloods for liver failure? (6)
- FBC – raised MCV
- LFTs – ↑ ALT, AST, GGT ( ↑ALP in later disease)
- ↓albumin (↓synthetic function)
- ↑ bilirubin in cirrhosis
- Clotting ↑ PTT (↓synthetic function)
- U+Es may be deranged in hepatorenal syndrome
What investigation can be used to assess degree of cirrhosis?
FibroScan - checks the elasticity of the liver
Why do an endoscopy for liver failure?
To assess for and treat oesophageal varices when portal hypertension is suspected
Why do an USS for liver failure?
May show fatty changes early on described as “increased echogenicity”
Can also demonstrate changes related to cirrhosis if present
Why do CT and MRI scans for liver failure?
To look for:
- Fatty infiltration of the liver
- Hepatocellular carcinoma
- Hepatosplenomegaly
- Abnormal BV changes
- Ascites
Why do a Liver Biopsy in a patient with suspected liver failure?
To confirm diagnosis of alcohol-related hepatitis or cirrhosis
NICE recommend considering a liver biopsy in patients where steroid treatment is being considered
General Management for a patient with Alcoholic Liver Disease
- STOP alcohol + manage withdrawal
- Prednisolone
- Treat complications of cirrhosis
- Referral for liver transplant in severe disease
How long must a patient abstain from alcohol for prior to referral for a liver transplant?
prior to referral
Describe the symptom timeline of alcohol withdrawl
6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delirium tremens”
What is Delirium Tremens?
Medical emergency associated with alcohol withdrawal with a mortality of 35% if left untreated.
What is the pathophysiology of Delirium Tremens
- Alcohol (+) GABA receptors and (-) glutamate receptors in the brain
- Results in inhibitory effect on electrical activity of the brain
- Chronic alcohol use down-regulates GABA and up-regulates glutamate
- Thus when alcohol is removed, GABA under-functions and glutamate over-functions causing extreme excitability and excess adrenergic activity
How does Delirium Tremens present?
- Acute confusion
- Severe agitation
- Delusions and hallucinations
- Tremor
- Tachycardia
- Hypertension
- Hyperthermia
- Ataxia
- Arrhythmias
How do we manage alcohol withdrawal
- CIWA-Ar tool (Clinical Institute Withdrawal Assessment – Alcohol revised) to score withdrawal symptoms and guide treatment
- Chlordiazepoxide - benzodiazepine
- IV Panbrinex IV (high-dose B vitamins, followed by regular lower dose Oral Thiamine
Alcohol excess leads to what deficiency?
What is the clinical name of this condition and how does it progress?
Thiamine (vitamin B1) → Wernicke-Korsakoff Syndrome
Wernicke’s encephalopathy comes before Korsakoffs syndrom
List 3 features of Wernicke’s encephalopathy? (NOAs)
- Nystagmus
- Ophthalmoplegia
- Ataxia
List 3 features of Korsakoffs syndrome (ARC)
- Anterograde memory loss
- Retrograde memory loss
- Confabulation
What is the importance of recognising WKS
How do we prevent this?
Wernicke’s encephalopathy is a medical emergency and has a high mortality rate if untreated.
Korsakoffs syndrome is irreversible and results in full time institutional care.
Prevention and treatment involve thiamine supplementation and abstaining from alcohol
