Alcoholic Liver Disease

Question 1

What can increase the risk of alcohol having a harmful effect on the liver? (2)

Answer 1

Obesity
Viral hepatitis

Question 2

What are the 3 steps of progression of alcohol-related liver disease?

Answer 2

1. Alcoholic fatty liver
2. Alcoholic hepatitis
3. Cirrhosis

Question 3

What is the main treatment of alcoholic fatty liver?

Answer 3

Abstinence
It is completely reversible

Question 4

Until what stage of alcohol related liver disease are the effects reversible on abstinence?

Answer 4

Mild alcoholic hepatitis

Question 5

What are the benefits of stopping drinking in alcohol related liver cirrhosis?

Answer 5

It prevents further damage to the liver

Question 6

What is the recommended alcohol consumption per week?

Answer 6

No more than 14 units a week
Spread over 3 or more days
No more than 5 units in a day

Question 7

What is the definition of binge drinking?

Answer 7

6 or more units for women
8 or more units for men

Question 8

What are some complications of drinking during pregnancy? (4)

Answer 8

Miscarriage
Small for dates
Preterm delivery
Fetal alcohol syndrome

Question 9

What are some complications of alcohol? (9)

Answer 9

• Alcohol-related liver disease
• Cirrhosis and its complications (e.g., hepatocellular carcinoma)
• Alcohol dependence and withdrawal
• Wernicke-Korsakoff syndrome (WKS)
• Pancreatitis
• Alcoholic cardiomyopathy
• Alcoholic myopathy, with proximal muscle wasting and weakness
• Increased risk of cardiovascular disease (e.g., stroke or myocardial infarction)
Increased risk of cancer, particularly breast, mouth and throat cancer

Question 10

What are some signs suggestive of excessive alcohol consumption? (5)

Answer 10

• Smelling of alcohol
• Slurred speech
• Bloodshot eyes
• Dilated capillaries on the face (telangiectasia)
• Tremor

Question 11

What happened to the MCV suggesting alcohol-related liver disease?

Answer 11

It is raised

Question 12

What LFTs would you see in alcohol-related liver disease?

Answer 12

Raised transaminases (AST:ALT ratio over 1.5)
Raised GGT
Raised ALP later in disease
Raised bilirubin in cirrhosis

Question 13

What happens to the investigations suggestive of synthetic function of the liver in alcohol-related liver disease? (2)

Answer 13

• Low albumin due to reduced synthetic function of the liver
Increased prothrombin time due to reduced synthetic function of the liver (reduced production of clotting factors)

Question 14

What does an ultrasound show in early alcoholic liver disease?

Answer 14

Fatty changes shown as increased echogenicity

Question 15

How is ultrasound used in patients with liver cirrhosis?

Answer 15

Used to screen for HCC

Question 16

What is transient elastography used for?

Answer 16

assess the elasticity of the liver using high-frequency sound waves. It helps determine the degree of fibrosis (scarring).

Question 17

What medical management can be given in severe alcoholic hepatitis? What effects does it have?

Answer 17

Corticosteroids
Reduces inflammation short term
No long term outcomes

Question 18

What are the general management principles of alcohol-related liver disease? (7)

Answer 18

• Stop drinking alcohol permanently (drug and alcohol services are available for support)
• Psychological interventions (e.g., motivational interviewing or cognitive behavioural therapy)
• Consider a detoxication regime
• Nutritional support with vitamins (particularly thiamine – vitamin B1) and a high-protein diet
• Corticosteroids may be considered to reduce inflammation in severe alcoholic hepatitis to improve short-term outcomes (but not long-term outcomes)
• Treat complications of cirrhosis (e.g., portal hypertension, varices, ascites and hepatocellular carcinoma)
• Liver transplant in severe disease (generally 6 months of abstinence is required)

Question 19

What 2 questionnaires can be used to screen for harmful alcohol use?

Answer 19

CAGE
AUDIT

Question 20

What is the CAGE questionnaire? What are the questions in it?

Answer 20

The CAGE questions can be used to quickly screen for harmful alcohol use:
• C – CUT DOWN? Do you ever think you should cut down?
• A – ANNOYED? Do you get annoyed at others commenting on your drinking?
• G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?

Question 21

What is the AUDIT questionnaire and how is it used?

Answer 21

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 indicates harmful use.

Question 22

What are the symptoms of alcohol withdrawal and what time frame do you experience each symptom? (4)

Answer 22

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

Question 23

What type of substance is alcohol?

Answer 23

Depressant

Question 24

What does alcohol do to GABA and glutamate receptors?

Answer 24

It stimulates GABA receptors in the brain.
GABA receptors have a relaxing effect on the rest of the brain.

Alcohol also inhibits glutamate receptors (also known as NMDA receptors), causing a further relaxing effect on the electrical activity of the brain (glutamate is an “excitatory” neurotransmitter).

Question 25

What happens to GABA and glutamate receptors with chronic alcohol use?

Answer 25

GABA system is down regulated
Glutamate system is upregulated

Question 26

Chronic alcohol use affects the GABA and glutamate systems. What happens when alcohol is removed from the system?

Answer 26

the GABA system under-functions and the glutamate system over-functions, causing extreme excitability of the brain and excessive adrenergic (adrenalin-related) activity.

Question 27

What is the presentation of delirium tremens? (9)

Answer 27

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

Question 28

What score is used to score patients on withdrawal symptoms and guide treatment?

Answer 28

CIWA-Ar score

Question 29

What is the CIWA-Ar score for?

Answer 29

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) tool can be used to score the patient on their withdrawal symptoms and guide treatment.

Question 30

What is the medical management of alcohol withdrawals and how long is it given?

Answer 30

Chlordiazepoxide (Librium) is a benzodiazepine used to combat the effects of alcohol withdrawal.
Diazepam is a less commonly used alternative.

It is given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g., 10 – 40 mg every 1 – 4 hours). The dose is reduced over 5-7 days.

Question 31

What medical management is used in alcohol withdrawal to prevent Wernicke-Korsakoff syndrome?

Answer 31

High-dose B vitamins (Pabrinex) is given intramuscularly or intravenously, followed by long-term oral thiamine.

Question 32

What is the cause of wernicke-korsakoff syndrome?

Answer 32

excess leads to thiamine (vitamin B1) deficiency. Thiamine is poorly absorbed in the presence of alcohol. Alcoholics often have poor diets and get many of their calories from alcohol

Question 33

What are the features of wernickes encephalopathy? (3)

Answer 33

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

Question 34

What are the features of Korsakoff’s syndrome? (2)

Answer 34

○ Memory impairment (retrograde and anterograde)
○ Behavioural changes