Alcoholic Liver Disease Flashcards
What causes ALD?
The effects of the long-term excessive consumption of alcohol on the liver. The onset is progressive of alcoholic liver disease varies between people, suggesting there may be a genetic predisposition to having harmful effects of alcohol on the liver.
Why is it believed that there is some genetic predisposition to the progression of ALD?
The onset is progressive of alcoholic liver disease varies between people, suggesting there may be a genetic predisposition to having harmful effects of alcohol on the liver.
What is the stepwise process of alcoholic liver disease?
- Alcohol-related fatty liver
- Alcoholic hepatitis
- Cirrhosis
What is alcohol-related fatty liver?
Drinking leads to a build-up of fat in the liver. If the drinking stops this process reverses in around 2 weeks.
What is alcoholic hepatitis
Drinking alcohol over a long period causes inflammation in the liver sites. Binge drinking is associated with the same effect. Mild alcoholic hepatitis is usually reversible with permanent abstinence.
What is cirrhosis?
This is where the liver is made up of scar tissue rather than healthy liver tissue. This is reversible. Stopping drinking can prevent further damage but continued drinking has a very poor prognosis.
What is the recommended alcohol consumption?
Not to drink more than 14 units per week for both men and women.
Should be spread evening over 3 or more days and not more than 5 units in a day.
What is the CAGE question?
C – CUT DOWN? Ever thought you should?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Ever feel guilty about drinking?
E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?
What is the AUDIT questionnaire?
The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organisation to screen people for harmful alcohol use. It involves 10 questions with multiple-choice answers and gives a score.
A score of 8 or more gives an indication of harmful use.
What are some complications of alcohol?
- Alcoholic Liver Disease
- Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma
- Alcohol Dependence and Withdrawl
- Wernicke-Korsakoff Syndrome (WKS)
- Pancreatitis
- Alcoholic Cardiomyopathy
What are the 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
What bloods would you do and find?
FBC - raised MCV
LFT’s - 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
Clotting - elevated prothrombin time due to reduced ‘synthetic function’ of the liver
U+Es may be deranged in hepatorenal syndrome
What would an ultrasound scan show in ALD?
May show fatty changes early on described as “increased echogenicity” (more light colors on the scan). It can also demonstrate changes related to cirrhosis if present.
What is a Fibroscan and what would it show in ALD?
Used to check the elasticity of the liver by sending high-frequency sound waves to the liver and assessing velocity and converting this to measurement which helps to assess the degree of cirrhosis.
Why would an endoscopy be used in ALD?
It can be used to assess for a treat oesophageal varices when portal hypertension is suspected
Why would a CT and MRI scan be used?
To look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
Why would a liver biopsy be used?
To confirm the diagnosis of alcohol-related hepatitis or cirrhosis.
NICE recommends considering a liver biopsy in patients where steroid treatment is being considered
What is the recommended general management of ALD?
Stop drinking alcohol permanently
Consider a detoxication regime
Nutritional support with vitamins (thiamine) and high protein diet
Steroids improve short-term outcomes in severe alcoholic hepatitis but infection and GI bleeding need to be treated first and do not improve outcomes over the long term
Treat complications of cirrhosis
Referal for liver transplant in severe disease -> must obtain abstain from alcohol for 3 months prior
What symptoms occur at the different stages of alcohol withdrawal?
6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delirium tremens”
What are delirium tremens?
It’s a medical emergency associated with alcohol withdrawal with a mortality of 35% if left untreated.
What is the pathophysiology of delirium tremens?
Alcohol stimulates GABA receptors in the brain.
GABA receptors have a “relaxing” effect on the rest of the brain.
Alcohol also inhibits glutamate receptors (NMDA) having a further inhibitory effect on the electrical activity of the brain.
Chronic alcohol use results in the downregulation of the GABA system and upregulation of the glutamate system to balance effects.
When alcohol is removed the brain is under extreme excitability with excess adrenergic activity.
What is the pathophysiology of delirium tremens?
Alcohol stimulates GABA receptors in the brain.
GABA receptors have a “relaxing” effect on the rest of the brain.
Alcohol also inhibits glutamate receptors (NMDA) having a further inhibitory effect on the electrical activity of the brain.
Chronic alcohol use results in the downregulation of the GABA system and upregulation of the glutamate system to balance effects.
When alcohol is removed the brain is under extreme excitability with excess adrenergic activity.
What does delirium tremens present as?
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias
What is the common medication used in alcohol withdrawal?
Chlordiazepoxide (“Librium”) is a benzodiazepine used to combat the effects of alcohol withdrawal.
It is given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (eg 10-40mg every 1-4 hours). This is continued for 5-7 days.
IV high dose B vitamins (pabrinex)
Should be followed by regular lower dose oral thiamine
