Alcoholic liver disease Flashcards
Progression of alcoholic liver disease
Alcohol related fatty liver –> alcoholic hepatitis –> cirrhosis
What are some of the complications of alcohol?
Alcoholic Liver Disease
Cirrhosis and its complications including hepatocellular carcinoma
Alcohol Dependence and Withdrawal
Wernicke-Korsakoff Syndrome (WKS)
Pancreatitis
Alcoholic Cardiomyopathy
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
Investigations in suspected Alcoholic Liver disease
FBC - shows raised MCV
LFTs -
- elevated ALT and AST (transaminases) and particularly raised gamma-GT.
- ALP will be elevated later in the disease.
- Low albumin due to reduced “synthetic function” of the liver.
- Elevated bilirubin in cirrhosis.
U&Es may be deranged in hepatorenal syndrome
Ultrasound liver
Fibroscan to assess degree of cirrhosis
Endoscopy to investigate for varices
Liver biopsy - can be used to confirm the diagnosis of alcohol-related hepatitis or cirrhosis. NICE recommend considering a liver biopsy in patients where steroid treatment is being considered.
What are the signs of decompensated liver disease?
Asterixis
Confusion
- These are due to encephalopathy
Ascites
Significant jaundice
What is the management of alcoholic liver disease?
Stop alcohol intake - advice on cutting down
Nutritional support (especially thiamine) and high protein diet
Steroids used to reduce inflammation in ALD
- Based on discriminant function score
- <32 steroids not needed as won’t improve mortality
- Prognosis is poor if score >32 - can use steroids (unless signs of infection)
- Only used in the short term (one month)
When can steroids be used in liver disease?
Only to be used in the case of decompensated liver disease due to alcohol
Only improve survival in short term
Also increase risk of severe infections so not more than 1 month treatment
What is Discriminant function?
Calculation based on PT and bilirubin that helps determine the prognosis of ALD
Only used in alcoholic hepatitis
For other causes of decompensated liver disease use either the Child-Pugh score or the MELD score
What are the Child-Pugh and MELD scores?
- Child-Pugh score – used to diagnose severity of cirrhosis of all causes (C is the worst prognosis)
- MELD score – predicts 3 month mortality
What are the symptoms of alcohol withdrawal?
6-12h:
- Tremor
- Sweating
- Craving
- Anxiety
- Headache
12-24h - hallucinations
24-48h - seizures
24-72h - delirium tremens
What is delirium tremens?
Medical emergency associated with alcohol withdrawal
Chronic alcohol causes GABA system to be down-regulated and glutamate system up-regulated
When alcohol is removed GABA therefore under-functions and glutamate over-functions
How does delirium tremens present?
Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hypertension Hyperthermia Ataxia (difficulties with coordinated movements) Arrhythmias
What is first line treatment for delirium tremens?
Oral lorazepam
Managing alcohol withdrawal
Chlordiazepoxide - given as a reducing regime usually for up to 7 days
IV high dose B vitamins (pabrinex)
- When stopped the patient should be commenced on oral thiamine
What are some complications of alcohol excess?
Liver disease and cirrhosis
Varices
Ascites
Wernicke’s encephalopathy
Korsakoff’s syndrome
