Alcoholic Liver Disease Flashcards
What quantity of alcohol is sufficient to cause alcoholic liver disease?
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
What is the first line treatment for alcoholic liver disease?
Alcohol abstinence
Enzyme tests to monitor ongoing liver damage
What are some complications of ALD?
Oesophageal or gastric variceal bleeding Ascites Coagulopathy Hepatic encephalopathy Liver cancer
What are the three defining stages of ALD?
fatty liver (steatosis)
alcoholic hepatitis (inflammation and necrosis)
alcoholic liver cirrhosis
What are risk factors for ALD?
Prolonged heavy alcohol consumption
Presence of hepatitis C
Female sex
What are common diagnostic factors for ALD?
Risk factors
Right upper abdominal discomfort
Hepatomegaly
Ascites Weight loss/gain Malnutrition and wasting Anorexia Fatigue
What are some less common diagnostic factors for ALD?
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
When is jaundice common?
Common in severe alcoholic hepatitis and in decompensated severe alcoholic cirrhosis
When is jaundice uncommon?
Uncommon in compensated alcoholic cirrhosis or alcoholic steatosis
What are cutaneous telangiectasia?
Vascular spiders with central arteriole flanked by smaller vessels. Usually seen on the trunk, face, and upper limbs.
What is asterixis?
Flapping motions of outstretched, dorsiflexed hands; quick test for encephalopathic state.
Manifestation of hepatic encephalopathy present in advanced ALD
How can ascites be evaluated?
Shifting dullness
Fluid wave examination
Why might patients with ALD loose weight?
High tumour necrosis factor (TNF)-alpha and inflammatory response
Leads to loss of appetite
Why might patients with ALD gain weight?
Ascites or oedema
What are some weaker risk factors for ALD?
Cigarette smoking Obesity Age > 65 Hispanic ethnicity Genetic predispostion
What are the 1st investigations to order is ALD?
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
What are AST and ALT?
AST - aspartate aminotransferase
ALT - alanine aminotransferase
What are the upper limit of normal values for ALT and AST?
30 units/L for men and 19 units/L for women
What happens to the ALT/AST ratio in ALD?
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
What would raised alkaline phosphatase suggest in ALD?
Cholestasis associated with ALD
What would happen to serum albumin in ALD?
Low
Impaired synthetic function of the liver
What would happen to gamma-GT in ALD?
Increase representing enzyme activation induced via alcohol
What could be seen on a FBC in ALD?
Anaemia
Leukocytosis
Thrombocytopenia
High MCV
What could cause anaemia in ALD?
Iron deficiency GI bleeding Folate deficiency Haemolysis Hypersplenism
What could be wrong with electrolytes in ALD?
Hyponatraemia
Hypokalaemia
Hypophosphataemia
Hypomagnesaemia
What does elevated INR/PT suggest in ALD pts?
Liver cirrhosis or liver failure
When should hepatic ultrasound be conducted in liver patients?
Pts with harmful alcohol abuse
Screen for hepatocellular carcinoma (every 6-12 months) for those with ALD
What abnormalities may be seen on an abnormal hepatic ultrasound?
Hepatomegaly Fatty liver Liver cirrhosis Liver mass Splenomegaly Ascites Evidence of portal hypertension
What investigations should be considered in ALD?
Viral hepatitis serology
Serum iron, ferritin, transferrin
Urine copper (24 hour)
> 40mg
= potentialWilsonn’s diseaaes e
eeum ceruloplasmin
Serum a
What are the histopathological features of alcoholic hepatitis?
Centrilobular ballooning Degeneration and necrosis of hepatocytes Steatosis - fatty change Neutrophilic inflammation Cholestasis Giant mitochondria
Summarise the epidemiology of alcoholic hepatitis
Occurs in 10-35% of heavy drinkers
Recognise the presenting symptoms of alcoholic hepatitis
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
What are some signs of alcoholic hepatitis on PE?
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
What are some signs of severe alcoholic hepatitis?
o Febrile (in 50% of patients)
o Tachycardia
o Jaundice
o Bruising
o Encephalopathy
o Ascites
o Hepatomegaly
o Splenomegaly
Describe the features of encephalopathy in alcoholic hepatitis?
(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
What is first line treatment for all patients?
Alcohol abstinence +/- withdrawal management
Weight reduction + smoking cessation
Nutritional supplementation + multivitamins (thiamine - pabrinex)
Immunisations
If severe- corticosteriods
What measures can be used to aid alcohol abstinence?
Counselling Brief intervention Psychotherapy AA Rehab programmes
What drugs are most commonly used to treat withdrawal?
Long acting benzodiazepines
- prevent seizures/delirium
Diazepam 10mg IV followed by 5-10mg every 3/4 hours
What is the management plan for acute alcoholic hepatitis?
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
What is 2nd line treatment for ALD?
Transplant
What are the possible complications of ALD?
Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
What immunisations are recommended for all ALD patients?
Flu
Pneumococcal
Hep A and Hep B if antibody tests are neg
What 3 enzymes convert alcohol to acetaldehyde in the liver?
Cytochrome p450
Alcohol DeHydrogenase
Catalase
How do you diagnose alcoholic liver disease?
AST>ALT
Raised WCC, reduced platelets
Neutrophilic leucocytosis
Mallory-denk body on histopathology
What is the treatment for encephalopathy caused by alcoholic liver disease?
Oral lactulose
Phosphate enemas
When might steroids be used?
To reduce short-term mortality for severe alcoholic hepatitis
What is Cirrhosis?
Irreversible end-stage liver damage
Regenerative nodules seen on histology
Band of protein around it
How is cirrhosis caused?
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
What causes portal hypertension?
Fibrotic tissue
Pressure compressed sinusoid and veins leading to portal hypertension
Fluid leaks to relieve pressure causing ascites
What causes cirrhosis?
Chronic alcoholic misuse - common in UK
Chronic viral hepatitis - common worldwide
What can precipitate decompensation?
Infection GI bleed Constipation Alcohol Drugs Portal vein thrombosis
What are the signs of cirrhosis?
Jaundice Distended abdomen Hepatic encephalopathy Splenomegaly Easy bruising Gynaecomastia Erythema
What are investigations for Cirrhosis?
FBC - reduced platelets
LFTs - raised ALT/AST/Bilirubin
Prolonged PT
Liver biopsy - gold standard
What is the management for cirrhosis?
Treat the cause
Treat the complications
Liver transplant
What are the key histological features of alcohol related liver disease?
Ballooning (+/- Mallory Denk Bodies)
Fat
Pericellular fibrosis
Mainly seen in zone 3 (around the central veins)
How as nomenclature changed re alc/non-alc liver disease?
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
