Alcoholic liver disease

Question 1

Briefly describe the cause of a fatty liver by alcohol?

Answer 1

1. Ethanol is metabolised in the liver by two pathways resulting in an increase in NADH and a decrease in NAD+
2. This alteration causes increased hepatic fatty acid synthesis and decreased fatty acid oxidation
3. Steatosis - fat deposits in the liver. Fatty liver is large, tender and greasy

Question 2

How does alcohol cause alcoholic hepatitis?

Answer 2

• Changes in oxidation-reduction impairs carb and protein metabolism = necrosis if hepatic acinus and the release of ROS which causes tissue damage and fibrosis
• Acetaldehyde binds to and inhibits macromolecules in the cell which immune system then attacks the hepatocytes

Question 3

What can be seen histologically in alcoholic hepatitis?

Answer 3

• Mallory bodies which are damaged intermediate filaments in hepatocytes

Question 4

What is alcoholic cirrhosis?

Answer 4

The progression of alcoholic hepatitis to irreversible scaring

Question 5

What are the risk factors for alcoholic liver disease?

Answer 5

• Alcohol abuse
• Genetic predisposition
• Immunological mechanisms

Question 6

What is the presentation of fatty liver disease?

Answer 6

• Often asymptotic
• vague abdo symptoms of nausea, vomiting, diarrhoea usually due to more general effect of alcohol on GI tract
• Hepatoegaly can occur

Question 7

What is the presentation of alcoholic hepatitis?

Answer 7

• Patient may be well with few symptoms and hepatitis only apparent on biopsy
• Mild - moderate = ill health, maybe mild jaundice, ascites, bruising, clubbing, dupuytrens contracture
• Severe = jaundice and ascites

Question 8

What is the presentation of alcoholic cirrhosis?

Answer 8

• Patient can we well with few symptoms
• On examination there are usually signs of chronic liver disease - ascites, bruising, clubbing and dupuytren’s contracture
• Usually features of alcohol dependency

Question 9

What investigations would you do to look for a fatty liver?

Answer 9

• Bloods to look for elevated MCV (indicates heavy drinking) and raise ALT and AST
• Imaging will show fatty infiltration

Question 10

What investigations would you do to look for alcoholic hepatitis or alcohol cirrhosis?

Answer 10

Bloods to look for

• Serum bilirubin
• AST and ALT
• Alkaline phosphate and GGT
• Prothrombin time

Question 11

What is the main treatment for alcoholic liver disease?

Answer 11

Stop drinking alcohol

Question 12

What is given in the treatment of alcoholic liver disease?

Answer 12

IV thiamine to prevent wernicke-korsakoff encephalopathy and advise a diet high in vitamins and proteins

Nb: alcoholics usually substitute food for alcohol and rely on that for calories so they are using malnourished