Alcoholic liver disease

Question 1

What are the stages of ALD?

Answer 1

Alcoholic fatty liver - drinking –> build up of fat in liver
Alcoholic hepatitis - inflamm from chronic drinking
Cirrhosis - irreversible scarring of liver tissue

Question 2

What is the recommended maximum alcohol consumption

Answer 2

14 units per week
Spread over 3 days
No more than 5 units per day
2 fully alcohol free days

Question 3

How do you calculate units?

Answer 3

[%ABV x volume (ml)]/1000
OR
%ABV x volume (litres)

Question 4

How would alcoholic fatty liver present?

Answer 4

Incidental finding
Raised liver enzymes especially GGT
Highly echogenic liver on ultrasound
Raised liver enzymes AST:ALT >2, ↑GGT

Question 5

How would an acute alcoholic hepatitis patient present?

Answer 5

Ill patient 
Fever 
Jaundice 
Leucocytosis
Raised liver enzymes AST:ALT >2, ↑GGT

Question 6

Alcohol increases the risk of all cancers, but which ones in particular?

Answer 6

Breast
Mouth
Throat

Question 7

Hepatic damage due to alcohol is:

Answer 7

Centrilobular - around the central vein in the lobule

Question 8

Autoimmune damage to the liver tends to be:

Answer 8

Peri-portal - around the portal tracts

Question 9

What are the complications of alcohol use?

Answer 9

Alcoholic liver disease 
Hepatitis 
Cirrhosis & complications of cirrhosis e.g. hepatocellular carcinoma
Alcohol dependence & withdrawal
Pancreatitis 
Alcoholic cardiomyopathy 
Wernicke-Korsakoff syndrome

Question 10

What are the effects of alcohol on the liver?

Answer 10

Fatty liver –> hepatitis –> cirrhosis

Question 11

What are the effects of alcohol on the GIT?

Answer 11

Gastritis 
PUD
Varices
Pancreatitis
Carcinoma

Question 12

What are the effects of alcohol on the CNS?

Answer 12

Cognitive impairment/ poor memory
Peripheral polyneuropathy (mainly sensory)
Wernicke's encephalopathy 
- confusion
- ataxia
- ophthalmoplegia --> nystagmus, LR palsy
Korsakoff's: amnesia --> confabulation
Fits/ falls

Question 13

What are the effects of alcohol on the heart?

Answer 13

HTN
Dilated cardiomyopathy
Arrhythmias e.g. AF

Question 14

What are the effects of alcohol on the blood?

Answer 14

↑MCV
Folate deficiency –> anaemia
B12 deficiency –> anaemia

Question 15

What are the CAGE screening questions?

Answer 15

CAGE
Cut down?
Annoyed by people criticising your drinking?
Guilty?
Eye-opener

Question 16

What is another tool used to gauge whether someone has an alcohol problem?

Answer 16

AUDIT
Alcohol use disorders identification test
by WHO
Score >8 = harmful use

Question 17

Signs of liver disease?

Answer 17

Jaundice
Clubbing --> PBC
Palmar erythema 
Dupytren's contracture 
Flapping tremor - asterixis
Spider naevi
Gynaecomastia 
Hepatomegaly 
Caput medusae
Ascites 
Bruising

Question 18

Investigations - which blood tests would you request and what would they show?

Answer 18

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

Question 19

Investigations - what imaging would you do?

Answer 19

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

Question 20

What are two CNS related complications of alcoholic liver disease?

Answer 20

Wernicke’s encephalopathy

Korsakoff’s syndrome

Question 21

What is Wernicke’s encephalopathy?

Answer 21

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

Question 22

What is Korsakoff’s syndrome

Answer 22

Anterograde and retrograde amnesia resulting in confabulation
Behavioural changes

Irreversible - requires institutionalised care
Prevention involves thiamine supplementation and abstinence from alcohol

Question 23

Which develops first out of Wernicke’s/ Korsakoff’s?

Answer 23

Wernicke’s encephalopathy occurs before Korsakoff’s

Question 24

What is the general management for ALD?

Answer 24

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