Alcoholic liver disease Flashcards
Why does alcohol damage the liver?
- Alcohol is directly toxic to the liver (especially with chronic exposure)
- Alcohol interrupts/affects many metabollic pathways like gluconeogenesis and lipid metabolism
What are the pathways for ethanol metabolism?
Oxidative:
Ethanol –> Acetaldehyde –> Acetate
Done by Dehydrogenase enzymes
Microsomal enzyme oxidation system:
Ethanol –> Acetaldehyde
Done by Cytochrome P45…
What is steatosis and how does alcohol cause it?
Steatosis means fatty liver
Fat builds up as alcohol interrupts the lipid metabolic pathway so it accumulates
What is steatohepatitis?
What is the long term effect on the liver?
Fatty liver with inflammation (neutrophilic infiltration)
Inflammation causes fibrosis. The scar tissue builds up and the liver becomes cirrhotic.
What are signs of chronic liver disease?
Ascites (distended abdomen)
Jaundice
Muscle wasting
Spider naevi
Gynaecomastia
Palmar erythema
Loss of axillar, pubic and chest hair
What lab tests will show alcohlic damage to the liver?
Raised AST:ALT ratio (>2)*
Raised Gamma Glutamyl Transferase (GGT)
Macrocytosis (enlarged RBCs)
Thrombocytopenia (low platelets)
Aspartate aminotransferase (AST)*
Alanine transaminase (ALT)
What imaging modality is best for showing fatty liver?
Ultrasound scan
What is hepatic encephalopathy?
Syndrome characterised by a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction/failure, after exclusion of brain disease
It happens when there is a rise in ammonia levels in the body, but the damaged liver cannot manage it
How is hepatic encephalopathy graded?
Graded 1-4:
1 - milnd confusion
4 - coma
What are the causes of hepatic encephalopathy?
(ie causes of raised ammonia levels)
Infection
Drugs
Constipation
GI bleed
Electrolyte disturbance
(in someone with a shitty liver)
Hepatic encephalopathy is diagnosed through ruling out other conditions such as neurological ones which cause the symptoms.
What causes/problems must be ruled out?
Infection
Hypoglycaemia
Intracranial bleed
How is hepatic encephalopathy treated?
Treat cause…
Bowel clear out, Lactulose (laxative), Enemas
Antibiotics
Supportive management:
- ITU
- Airway support
- Nasogastric tube for meds
What is lactulose?
A laxative
Given rectally in hepatic encephalopathy
Symptoms for spontaneous bacterial peritonitis?
Abdominal pain
Fever
Rigors (shivering/feeling cold)
N&V (sepsis)
What are the signs of spontaneous bacterial peritonitis?
Ascites
Sepsis - malaise, N&Vs etc
Tachycardia
Pyrexia
Signs of renal impairment
How is spontaneous bacterial peritonitis investigated?
Ascitic tap procedure (peritonocentesis)
- fluid protein & glucose levels
- cultures
- cell count (SBP –> neutrophilia)
This is a type of paracentesis when ascites fluid is drained from the peritoneum. It can be used to investigate (samples) and to fully drain the fluid.
What is done with the fluid sample taken in an ascitic tap procedure?
(give values needed for diagnosis)
Protein levels <25g/L
Glucose levels
Cultures - typically E.coli
White cell content - Neutrophil count >0.25x109 /L
What must be excluded to diagnose spontaneous bacterial peritonitis?
Surgical causes must be excluded
How is spontaneous bacterial peritonitis be treated?
- IV antibiotics
- Ascitic fluid drainage (ascitic tap)
- +/- IV albumin infusion (20% ALBA) - holds fluid in the vasculature so ascites doesnt refill after drainage
What is alcoholic hepatitis and how does it present?
Inflammation of the liver due to excess alcohol intake. Often associated with steatosis/steatohepatitis.
It can cause cirrhosis, presenting with:
Jaundice
Encephalopathy
Infection common
Decompensated hepatic function
What measurements indicate decompensated hepatic function?
Low albumin
Raised prothrombin time (aka INR)
What does prothrombin time actually mean?
Basically how long the blood takes to clot
How is a diagnosis of Alcoholic hepatitis made?
- low albumin
- raised INR (prothrombin)
- raised bilirubin
- raised GGT & ALP
- history of excess alcohol
- exclusion through imaging of cancer or other causes
What is the prognosis for alcoholic hepatitis?
40% mortality
In severe cases, 90% mortality
Also higher if patient:
- Continues drinking alcohol
- Presented with encephalopathy
How is alcoholic hepatitis treated?
Supportive
Steroids (if severe)
Treat infection
Treat encephalopathy
Treat alcohol withdrawal
Protect against GI bleeding
Airway Protection / ITU care
How severe must alcoholic hepatitis be before treatment with steroids is indicated?
Glasgow Alcoholic Hepatitis Score >9
or
Maddrey’s discriminant function >32
What is Maddreys discriminant function?
Maddrey discriminant function (DF) is the traditional model for evaluating the severity and prognosis in alcoholic hepatitis and evaluates the efficacy of using alcoholic hepatitis steroid treatment
What nutritional management is given to people with alcoholic hepatitis?
High energy/calorie intake
High thiamine intake
Frequent feeds
+/- Consultation with dietician
How many people in the population have a ‘fatty liver’?
25-40%
What are risk factors/causes of fatty liver development?
Obesity
Diabetes
Hypercholesterolaemia
High alcohol intake
Steatohepatitis (fat + inflammation) is histologically similar to what?
Liver damaged by alcohol
‘A 1/4 of patients with steatohepatitis will develop ______’
Liver cirrhosis
What are the symptoms of Steatohepatitis?
Asymptomatic
What signs/investigations show steatohepatitis?
Raised Alanine amino transferase
Fatty liver on USS
Liver Biopsy
How is steatohepatitis treated?
Weight loss
Exercise
