Alcoholic liver disease

Question 1

Alcoholic liver disease definition

Answer 1

• liver damage caused by chronic heavy alcohol intake
• steatosis
• alcoholic hepatitis (inflammation and necrosis)
• alcoholic liver cirrhosis

Question 2

Alcoholic liver disease risk factors

Answer 2

• high alcohol use
• hepatitis C
• female (lower alcohol tolerance although most cases are male)

Question 3

Alcoholic liver disease pathophysiology

Answer 3

• alcohol dehydrogenase and acetaldehyde dehydrogenase reduce NAD to NADH
• higher NADH inhibits gluconeogenesis and increases fatty acid oxidation
• promotes fatty infiltration of liver
• CYP2E1 is upregulated, increasing free radicals

Question 4

Alcoholic liver disease signs and symptoms

Answer 4

• may be asymptomatic until decompensation
• abdominal pain
• jaundice
• hepatomegaly
• splenomegaly
• haematemesis
• melena
• venous, e.g. spider naevi
• palmar erythema
• ascites
• asterixis
• hepatic encephalopathy

Question 5

Alcoholic liver disease investigations

Answer 5

• FBC
• U&Es (magnesium, phosphate)
• LFTs (AST:ALT usually > 2)
• clotting screen
• hepatic ultrasound

Question 6

Alcoholic liver disease complications

Answer 6

• hepatic encephalopathy
• portal hypertension
• oesophageal varices
• GI bleeds
• coagulopathy
• renal failure
• hepatorenal syndrome
• sepsis

Question 7

Alcoholic hepatitis

Answer 7

• acute inflammation presenting with rapid onset jaundice, malaise, tender hepatomegaly
• AST:ALT > 2
• manage with glucocorticoids (Maddrey’s function)
• second line pentoxyphylline

Question 8

Varices and bleeding

Answer 8

• secondary to portal hypertension
• cause oesophageal vein distension
• increase bleeding and risk of death
• prophylaxis - beta blocker, band ligation, TIPSS
• correct clotting with FFP, platelets
• Terlipressin, 2nd line ocreotide
• prophylactic antibiotics - quinolones
• endoscopy and band ligation, TIPSS

Question 9

Ascites

Answer 9

• abnormal fluid collection in abdomen
• can be related to portal hypertension
• low salt diet and fluid restriction
• aldosterone antagonists, e.g. spironolactone, loop diuretics
• drainage of tense ascites
• IV albumin for large volume paracentesis
• prophylactic ciprofloxacin to prevent spontaneous bacterial peritonitis
• consider TIPSS

Question 10

Spontaneous bacterial peritonitis

Answer 10

• peritonitis in patients with ascites secondary to liver cirrhosis
• most commonly due to E. Coli
• presents with ascites, abdominal pain and fever - investigate with paracentesis
• manage with IV cefotaxime
• prophylaxis with oral ciprofloxacin or norfloxacin

Question 11

Hepatorenal syndrome

Answer 11

• kidneys reduce blood flow distribution in response to altered blood flow in the liver
• extreme vasodilation decreases mean arterial pressure

Question 12

Hepatic encephalopathy

Answer 12

• neuropsychiatric syndrome due to hepatic insufficiency
• likely due to excess ammonia and glutamine > brain atrophy, oedema
• lack of awareness, altered sleep, low attention span, euphoria/anxiety
• confusion, inappropriate behaviour, incoherence, restlessness, coma
• treat underlying cause, give lactulose and rifaximin