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Year 3 Gastro > Alcoholic Liver Disease > Flashcards

Alcoholic Liver Disease Flashcards

1
Q

What quantity of alcohol is sufficient to cause alcoholic liver disease?

A

40 to 80 g/day in men and 20 to 40 g/day in women for 10 to 12 years

in absence of co-morbidities

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2
Q

What is the first line treatment for alcoholic liver disease?

A

Alcohol abstinence

Enzyme tests to monitor ongoing liver damage

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3
Q

What are some complications of ALD?

A 
Oesophageal or gastric variceal bleeding
Ascites
Coagulopathy
Hepatic encephalopathy
Liver cancer
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4
Q

What are the three defining stages of ALD?

A

fatty liver (steatosis)

alcoholic hepatitis (inflammation and necrosis)

alcoholic liver cirrhosis

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5
Q

What are risk factors for ALD?

A

Prolonged heavy alcohol consumption
Presence of hepatitis C
Female sex

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6
Q

What are common diagnostic factors for ALD?

A

Risk factors
Right upper abdominal discomfort
Hepatomegaly

Ascites
Weight loss/gain
Malnutrition and wasting
Anorexia
Fatigue
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7
Q

What are some less common diagnostic factors for ALD?

A

Haematemesis and melaena

Venous collaterals - caput medusae, engorged para-umbilical veins

Splenomegaly

Hepatic mass

Jaundice

Palmar erythema - thenar and hypothenar eminences, sparing central portions

Cutaneous telangiectasia

Asterixis

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8
Q

When is jaundice common?

A

Common in severe alcoholic hepatitis and in decompensated severe alcoholic cirrhosis

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9
Q

When is jaundice uncommon?

A

Uncommon in compensated alcoholic cirrhosis or alcoholic steatosis

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10
Q

What are cutaneous telangiectasia?

A

Vascular spiders with central arteriole flanked by smaller vessels. Usually seen on the trunk, face, and upper limbs.

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11
Q

What is asterixis?

A

Flapping motions of outstretched, dorsiflexed hands; quick test for encephalopathic state.

Manifestation of hepatic encephalopathy present in advanced ALD

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12
Q

How can ascites be evaluated?

A

Shifting dullness

Fluid wave examination

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13
Q

Why might patients with ALD loose weight?

A

High tumour necrosis factor (TNF)-alpha and inflammatory response

Leads to loss of appetite

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14
Q

Why might patients with ALD gain weight?

A

Ascites or oedema

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15
Q

What are some weaker risk factors for ALD?

A 
Cigarette smoking
Obesity
Age > 65
Hispanic ethnicity
Genetic predispostion
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16
Q

What are the 1st investigations to order is ALD?

A 
Serum AST and ALT
AST/ALT ratio
Alkaline phosphatase
Bilirubin
Albumin/protein
Gamma glutamyl transferase
FBC
Electrolytes, Mg, phosphorus
Urea and Cr
PT and INR
Hepatic ultrasound
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17
Q

What are AST and ALT?

A

AST - aspartate aminotransferase

ALT - alanine aminotransferase

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18
Q

What are the upper limit of normal values for ALT and AST?

A

30 units/L for men and 19 units/L for women

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19
Q

What happens to the ALT/AST ratio in ALD?

A

AST elevated more than ALT

AST/ALT > 2 seen in 70% of cases

Ratio reversal where ALT>AST suggests viral hepatitis or non-alcoholic fatty liver disease

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20
Q

What would raised alkaline phosphatase suggest in ALD?

A

Cholestasis associated with ALD

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21
Q

What would happen to serum albumin in ALD?

A

Low

Impaired synthetic function of the liver

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22
Q

What would happen to gamma-GT in ALD?

A

Increase representing enzyme activation induced via alcohol

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23
Q

What could be seen on a FBC in ALD?

A

Anaemia
Leukocytosis
Thrombocytopenia
High MCV

24
Q

What could cause anaemia in ALD?

A 
Iron deficiency
GI bleeding
Folate deficiency
Haemolysis 
Hypersplenism
25
Q

What could be wrong with electrolytes in ALD?

A

Hyponatraemia
Hypokalaemia
Hypophosphataemia
Hypomagnesaemia

26
Q

What does elevated INR/PT suggest in ALD pts?

A

Liver cirrhosis or liver failure

27
Q

When should hepatic ultrasound be conducted in liver patients?

A

Pts with harmful alcohol abuse

Screen for hepatocellular carcinoma (every 6-12 months) for those with ALD

28
Q

What abnormalities may be seen on an abnormal hepatic ultrasound?

A 
Hepatomegaly
Fatty liver
Liver cirrhosis
Liver mass
Splenomegaly
Ascites 
Evidence of portal hypertension
29
Q

What investigations should be considered in ALD?

A

Viral hepatitis serology

Serum iron, ferritin, transferrin

Urine copper (24 hour)
> 40mg
= potentialWilsonn’s diseaaes e

eeum ceruloplasmin
Serum a

30
Q

What are the histopathological features of alcoholic hepatitis?

A 
Centrilobular ballooning
Degeneration and necrosis of hepatocytes
Steatosis - fatty change
Neutrophilic inflammation
Cholestasis
Giant mitochondria
31
Q

Summarise the epidemiology of alcoholic hepatitis

A

Occurs in 10-35% of heavy drinkers

32
Q

Recognise the presenting symptoms of alcoholic hepatitis

A

May remain asymptomatic and undetected

May be mild illness with symptoms such as:

o Nausea
o Malaise
o Epigastric pain
o Right hypochondrial pain
o Low-grade fever

More severe presenting symptoms include:

o Jaundice
o Abdominal discomfort or swelling
o Swollen ankles
o GI bleeding

33
Q

What are some signs of alcoholic hepatitis on PE?

A

o Malnourished

o Palmar erythema

o Dupuytren’s contracture

o Facial telangiectasia – red lines appear due to widened venules

o Parotid enlargement

o Spider naevi

o Gynaecomastia

o Testicular atrophy

o Hepatomegaly

o Easy bruising

34
Q

What are some signs of severe alcoholic hepatitis?

A

o Febrile (in 50% of patients)

o Tachycardia

o Jaundice

o Bruising

o Encephalopathy

o Ascites

o Hepatomegaly

o Splenomegaly

35
Q

Describe the features of encephalopathy in alcoholic hepatitis?

A

(e.g. liver flap, drowsiness, disorientation) – caused by build up of ammonia in blood (which is normally removed by the liver) – crosses blood-brain barrier

36
Q

What is first line treatment for all patients?

A

Alcohol abstinence +/- withdrawal management

Weight reduction + smoking cessation

Nutritional supplementation + multivitamins (thiamine - pabrinex)

Immunisations

If severe- corticosteriods

37
Q

What measures can be used to aid alcohol abstinence?

A 
Counselling
Brief intervention
Psychotherapy
AA
Rehab programmes
38
Q

What drugs are most commonly used to treat withdrawal?

A

Long acting benzodiazepines
- prevent seizures/delirium
Diazepam 10mg IV followed by 5-10mg every 3/4 hours

39
Q

What is the management plan for acute alcoholic hepatitis?

A

o Thiamine

o Vitamin C and other multivitamins (can be given as Pabrinex)

o Monitor and correct K+, Mg2+ and glucose

o Ensure adequate urine output

o Treat encephalopathy with oral lactulose or phosphate enemas – decrease ammonia generation by bacteria

o Ascites - manage with diuretics (spironolactone with/without furosemide)

o Therapeutic paracentesis (removing fluid)

o Glypressin and N-acetylcysteine for hepatorenal syndrome

40
Q

What is 2nd line treatment for ALD?

A

Transplant

41
Q

What are the possible complications of ALD?

A

Acute liver decompensation
Hepatorenal syndrome
Cirrhosis

42
Q

What immunisations are recommended for all ALD patients?

A

Flu
Pneumococcal
Hep A and Hep B if antibody tests are neg

43
Q

What 3 enzymes convert alcohol to acetaldehyde in the liver?

A

Cytochrome p450
Alcohol DeHydrogenase
Catalase

44
Q

How do you diagnose alcoholic liver disease?

A

AST>ALT
Raised WCC, reduced platelets
Neutrophilic leucocytosis
Mallory-denk body on histopathology

45
Q

What is the treatment for encephalopathy caused by alcoholic liver disease?

A

Oral lactulose

Phosphate enemas

46
Q

When might steroids be used?

A

To reduce short-term mortality for severe alcoholic hepatitis

47
Q

What is Cirrhosis?

A

Irreversible end-stage liver damage
Regenerative nodules seen on histology
Band of protein around it

48
Q

How is cirrhosis caused?

A

Fibrosis is mediated by stellate cells, usually dormant cells that store vitamin A

Damaged hepatocytes release factors that activate cells

Release vitamin A, start proliferating and produce tgf-beta

TGF-beta cause collagen formation which causes fibrotic tissues

Pressure compressed sinusoid and veins leading to portal hypertension

49
Q

What causes portal hypertension?

A

Fibrotic tissue

Pressure compressed sinusoid and veins leading to portal hypertension

Fluid leaks to relieve pressure causing ascites

50
Q

What causes cirrhosis?

A

Chronic alcoholic misuse - common in UK

Chronic viral hepatitis - common worldwide

51
Q

What can precipitate decompensation?

A 
Infection
GI bleed
Constipation
Alcohol
Drugs
Portal vein thrombosis
52
Q

What are the signs of cirrhosis?

A 
Jaundice
Distended abdomen
Hepatic encephalopathy
Splenomegaly
Easy bruising 
Gynaecomastia
Erythema
53
Q

What are investigations for Cirrhosis?

A

FBC - reduced platelets
LFTs - raised ALT/AST/Bilirubin
Prolonged PT
Liver biopsy - gold standard

54
Q

What is the management for cirrhosis?

A

Treat the cause
Treat the complications
Liver transplant

55
Q

What are the key histological features of alcohol related liver disease?

A

Ballooning (+/- Mallory Denk Bodies)
Fat
Pericellular fibrosis
Mainly seen in zone 3 (around the central veins)

56
Q

How as nomenclature changed re alc/non-alc liver disease?

A

MAFLD - metabolic associated fatty liver disease

MASH - metabolic associated steatohepatitis

some pts have alcoholic/fatty due to obesity/metabolic changes so cannot strictly classify as alc or non-alc

Year 3 Gastro (39 decks)

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