Alcoholic Liver Disease

Question 1

What causes ALD?

Answer 1

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.

Question 2

Why is it believed that there is some genetic predisposition to the progression of ALD?

Answer 2

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.

Question 3

What is the stepwise process of alcoholic liver disease?

Answer 3

1. Alcohol-related fatty liver
2. Alcoholic hepatitis
3. Cirrhosis

Question 4

What is alcohol-related fatty liver?

Answer 4

Drinking leads to a build-up of fat in the liver. If the drinking stops this process reverses in around 2 weeks.

Question 5

What is alcoholic hepatitis

Answer 5

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.

Question 6

What is cirrhosis?

Answer 6

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.

Question 7

What is the recommended alcohol consumption?

Answer 7

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.

Question 8

What is the CAGE question?

Answer 8

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?

Question 9

What is the AUDIT questionnaire?

Answer 9

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.

Question 10

What are some complications of alcohol?

Answer 10

• Alcoholic Liver Disease
• Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma
• Alcohol Dependence and Withdrawl
• Wernicke-Korsakoff Syndrome (WKS)
• Pancreatitis
• Alcoholic Cardiomyopathy

Question 11

What are the signs of liver disease?

Answer 11

• 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

Question 12

What bloods would you do and find?

Answer 12

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

Question 13

What would an ultrasound scan show in ALD?

Answer 13

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.

Question 14

What is a Fibroscan and what would it show in ALD?

Answer 14

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.

Question 15

Why would an endoscopy be used in ALD?

Answer 15

It can be used to assess for a treat oesophageal varices when portal hypertension is suspected

Question 16

Why would a CT and MRI scan be used?

Answer 16

To look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites

Question 17

Why would a liver biopsy be used?

Answer 17

To confirm the diagnosis of alcohol-related hepatitis or cirrhosis.

NICE recommends considering a liver biopsy in patients where steroid treatment is being considered

Question 18

What is the recommended general management of ALD?

Answer 18

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

Question 19

What symptoms occur at the different stages of alcohol withdrawal?

Answer 19

6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delirium tremens”

Question 20

What are delirium tremens?

Answer 20

It’s a medical emergency associated with alcohol withdrawal with a mortality of 35% if left untreated.

Question 21

What is the pathophysiology of delirium tremens?

Answer 21

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.

Question 22

What is the pathophysiology of delirium tremens?

Answer 22

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.

Question 23

What does delirium tremens present as?

Answer 23

Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias

Question 24

What is the common medication used in alcohol withdrawal?

Answer 24

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

Question 25

What is Wernicke-Korsakoff Syndrome (WKS)?

Answer 25

Alcohol excess leads to thiamine (vitamin B1) deficiency.

Thiamine is poorly absorbed in the presence of alcohol and alcoholics tend to have poor diets and rely on alcohol for calories.

Wernicke’s encephalopathy comes before Korsakoffs syndrome. These result from thiamine deficiency.

Question 26

What are the features of Wernicke’s encephalopathy?

Answer 26

Confusion
Oculomotor disturbances (disturbances of eye movements)
Ataxia (difficulties with coordinated movements)

Question 27

What are the features of Korsakoffs syndrome?

Answer 27

Memory impairment (retrograde and anterograde)
Behavioral changes