Alcoholic liver disease Flashcards
What are the stages of ALD?
Alcoholic fatty liver - drinking –> build up of fat in liver
Alcoholic hepatitis - inflamm from chronic drinking
Cirrhosis - irreversible scarring of liver tissue
What is the recommended maximum alcohol consumption
14 units per week
Spread over 3 days
No more than 5 units per day
2 fully alcohol free days
How do you calculate units?
[%ABV x volume (ml)]/1000
OR
%ABV x volume (litres)
How would alcoholic fatty liver present?
Incidental finding
Raised liver enzymes especially GGT
Highly echogenic liver on ultrasound
Raised liver enzymes AST:ALT >2, ↑GGT
How would an acute alcoholic hepatitis patient present?
Ill patient Fever Jaundice Leucocytosis Raised liver enzymes AST:ALT >2, ↑GGT
Alcohol increases the risk of all cancers, but which ones in particular?
Breast
Mouth
Throat
Hepatic damage due to alcohol is:
Centrilobular - around the central vein in the lobule
Autoimmune damage to the liver tends to be:
Peri-portal - around the portal tracts
What are the complications of alcohol use?
Alcoholic liver disease Hepatitis Cirrhosis & complications of cirrhosis e.g. hepatocellular carcinoma Alcohol dependence & withdrawal Pancreatitis Alcoholic cardiomyopathy Wernicke-Korsakoff syndrome
What are the effects of alcohol on the liver?
Fatty liver –> hepatitis –> cirrhosis
What are the effects of alcohol on the GIT?
Gastritis PUD Varices Pancreatitis Carcinoma
What are the effects of alcohol on the CNS?
Cognitive impairment/ poor memory Peripheral polyneuropathy (mainly sensory) Wernicke's encephalopathy - confusion - ataxia - ophthalmoplegia --> nystagmus, LR palsy Korsakoff's: amnesia --> confabulation Fits/ falls
What are the effects of alcohol on the heart?
HTN
Dilated cardiomyopathy
Arrhythmias e.g. AF
What are the effects of alcohol on the blood?
↑MCV
Folate deficiency –> anaemia
B12 deficiency –> anaemia
What are the CAGE screening questions?
CAGE Cut down? Annoyed by people criticising your drinking? Guilty? Eye-opener
What is another tool used to gauge whether someone has an alcohol problem?
AUDIT
Alcohol use disorders identification test
by WHO
Score >8 = harmful use
Signs of liver disease?
Jaundice Clubbing --> PBC Palmar erythema Dupytren's contracture Flapping tremor - asterixis Spider naevi Gynaecomastia Hepatomegaly Caput medusae Ascites Bruising
Investigations - which blood tests would you request and what would they show?
FBC –> ↑MCV, ↑WCC
U&Es –> may be deranged in hepatorenal syndrome
LFTs –> ↑AST & ALT, ↑GGT (particularly raised)
↑ALP, ↑bilirubin
Low albumin - reduced synthetic liver function
Clotting –> prolong prothrombin time - reduced synthetic liver function
Investigations - what imaging would you do?
Ultrasound - may show increased echogenicity of the liver due to damage, cirrhotic scar tissue
Fibroscan - looks at the elasticity of the liver and helps to assess the degree of cirrhosis
Endoscopy to assess and treat oesophageal varices if portal hypertension is suspected
CT/ MRI - look for fatty infiltration, hepatosplengomegaly, hepatocellular carcinoma, abnormal blood vessel changes and ascites
Liver biopsy - used to confirm cirrhosis or alcohol related hepatitis diagnosis - NICE recommends prior to steroid therapy
What are two CNS related complications of alcoholic liver disease?
Wernicke’s encephalopathy
Korsakoff’s syndrome
What is Wernicke’s encephalopathy?
Triad of:
Confusion
Ophthalmoplegia/ oculomotor disturbances
Ataxia
due to B1 thiamine deficiency –> poorly absorbed in the presence of alcohol and alcoholics have a poor diet anyway
What is Korsakoff’s syndrome
Anterograde and retrograde amnesia resulting in confabulation
Behavioural changes
Irreversible - requires institutionalised care
Prevention involves thiamine supplementation and abstinence from alcohol
Which develops first out of Wernicke’s/ Korsakoff’s?
Wernicke’s encephalopathy occurs before Korsakoff’s
What is the general management for ALD?
Abstinence
Group therapies/ charities - AA
Detox regime - chlordiazepoxide
Nutritional support with vitamins (pabrinex) especially Thiamine + high protein diet
Steroids improve short term outcomes >1month in severe alcoholic hepatitis but treat infection and GI bleeding first
Baclofen - reduces cravings
Disulfiram - aversion therapy
Treat complications of cirrhosis - portal htn, varices, ascites, hepatic encephalopathy
Refer for liver transplant in severe disease –> alcohol free for 3 months before referral
