Alcoholic Liver Disease

Question 1

Definition =
Relative amounts for men and women

Answer 1

Chronic heavy alcohol ingestion = most common cause of decompensated cirrhosis
- 40-80g/day = MEN
- 20-40g/day = WOMEN
For 10-12 years

Question 2

3 stages of liver damage

Answer 2

Fatty liver (steatosis)
Alcohol hepatitis (inflammation + necrosis)
Alcoholic liver cirrhosis

Question 3

Epidemiology

Answer 3

Female sex

Question 4

Risk factors

Answer 4

• Prolonged heavy alcohol consumption
• Concomitant liver disease e.g. Hepatitis C: ALD can occur with low alcohol consumption
• Cigarette smoking = fibrosis progresses more rapidly in patients with ALD
• Overweight = risk of ALD is at least 2 times higher in overweight people
• > 65

Question 5

Pathophysiology

Answer 5

Alcohol broken down by 2 main pathways:
- Alcohol dehydrogenase = hepatic enzyme which converts alcohol -> acetaldehyde which is metabolised to acetate by acetaldehyde dehydrogenase. Alcohol dehydrogenase + acetaldehyde dehydrogenase converts NAD -> NADH. Excess NADH inhibits gluconeogenesis = promotes fatty infiltration in the liver. Less NAD+ = less fatty acid oxidation. Both leads to more fat in liver = STEATOSIS (reversible
- Cytochrome 2E1 =produces more free radicals.
- Chronic alcohol exposure also activates hepatic macrophages which produces tumour necrosis factors (TNF) = induce the production of reactive oxygen species in mitochondria = hepatic inflammation.
Chronic inflammation eventually leads to liver fibrosis + eventually cirrhosis

Question 6

Signs

Answer 6

Hand signs:
- Palmer erythema
- Dupuytren’s contracture
Jaundice
Ascites
Spider naevi
Confusion + Asterixis
Hepatosplenomegaly
Caput medusae
Parotid gland enlargement
Feminisation: gynaecomastia, hypogonadism
Hepatic mass: suggest HCC
Haematemesis

Question 7

Symptoms

Answer 7

Early stage = completely asymptomatic
Late more severe stages = chronic/liver failure Sx + alcohol dependency
Non-specific:
- Malaise
- Weakness
- Weight loss
Abdominal discomfort: RUQ
Pruritus
Easy bruising

Question 8

Alcohol dependency questionnaires include CAGE + AUDIT

Answer 8

CAGE:
should you CUT down
are people Annoyed by your drinking
feel Guilty about drinking
you drink in morning (Eye opening)
2 < dependant
AUDIT: 1st line = 10 questions = alcohol use disorder ID test

Question 9

Diagnosis

Answer 9

FIRST LINE: LFT’s
- Serum aspartate aminotransferases (AST), alanine aminotransferase (ALD) = AST usually higher (2:1)
- GGT + ALP raised
- Bilirubin raised
- Albumin low
- Prothrombin/INR: high suggests advanced liver disease
FBC = micro cystic anaemia
GOLD STANDARD: Liver biopsy
- can grade level of fibrosis to see which stage it is at
- Neutrophil infiltrates,
- Mallory cytoplasmic inclusion bodies,
- Increased fat cells

Question 10

Management

Answer 10

FIRST LINE = Alcohol abstinence + Alcohol withdrawal management (delirium, tremors)
- OXAZEPAM = 15-30mg, orally 3-4 times daily
or
- DIAZEPAM = 10mg IV followed by 5-10gm every 3-4 hours when required
or
LORAZEPAM= 2-6mg/day orally 2-3 divided doses
Healthy diet + Reduce BMI
Pharmacological = consider short term steroids (Maddrey’s discriminant value = INR + serum bilirubin = 32+) + N-acetylcysteine (severe)
B1 + folate
Surgical = liver transplant (abstain 3 months prior)

Question 11

Complications

Answer 11

Pancreatitis (IgE)
HE - lactulose
Ascites - diuretics
HCC - chemo, surgery
Mallory wiess tear
WERNICKE KORSAKOFF SYNDROME

Question 12

WERNICKE KORSAKOFF SYNDROME

Answer 12

Combined B1 deficiency (alcohol causes B1 def) and alcohol withdrawal Sx.
- Ataxia
- Nystagmus
- Encephalopathy
- Disproportional increase in memory loss
Tx = IV THIAMINE