Alcoholic Liver Disease Flashcards
What are the 3 stages of alcoholic liver disease (ALD)?
3 stages of liver damage:
- Fatty liver (steatosis)
- Alcoholic hepatitis (inflammation and necrosis)
- Alcoholic liver cirrhosis
Briefly describe the pathophysiology of ALD
Alcohol is metabolized mainly in the liver, through 2 main pathways: alcohol dehydrogenase and cytochrome P-450 2E1.
Chronic alcohol exposure also activates a third site of metabolism: hepatic macrophages, which produce tumor necrosis factor (TNF)-alpha and induce the production of reactive oxygen species in the mitochondria.
What risk factors are associated with ALD?
- Prolonged and heavy alcohol consumption
- Hepatitis C
- Female sex
- Cigarette smoking
- Obesity
What are the signs of ALD?
- Hepatomegaly
- Haematemesis and malene
- Venous collaterals
- Splenomegaly
- Hepatic mass
- Jaundice
- Palmar erythema
- Cutaneous telangiectasia
- Asterixis
What are the symptoms of ALD?
- Abdominal pain (RUQ)
- Weight loss or weight gain
- Fatigue
What investigations should be ordered in ALD?
- Serum AST and ALT
- Serum AST:ALT ratio
- Serum alkaline phosphatase
- Serum bilirubin
- Serum albumin and protein
- Serum gamma glutamyl transferase (gamma-GT)
- FBC
- Serum electrolytes, magnesium and phosphorus
- Serum BUN and creatinine
- Serum prothombin time and INR
- Hepatic ultrasound
Why investigate serum AST and ALT? And what may this show?
- AST and ALT is elevated in ALD when alcohol use >50 g/day
- Elevated
Why investigate serum AST:ALT ratio? And what may this show?
- In patients with ALD, AST level is almost always elevated (usually above ALT level). The classic ratio of AST/ALT >2 is seen in about 70% of cases.Reversal of the ratio, ALT > AST, suggests concomitant presence of viral hepatitis or possibly nonalcoholic fatty liver disease as the major cause of liver injury in alcoholic patients.
- Ratio >2
Why investigate serum alkaline phosphatase? And what may this show?
- If elevated may represent cholestasis associated with ALD
- Normal or elevated
Why investigate serum bilirubin? And what may this show?
- Both conjugated and unconjugated bilirubin are increased in varying proportion.Elevated bilirubin reflects impaired metabolic function of the liver in the absence of biliary obstruction.
- Elevated
Why investigate serum albumin and protein? And what may this show?
- Low albumin reflects impaired synthetic function of the liver
- Low
Why investigate serum gamma glutamyl transferase (gamma-GT)? And what may this show?
- Gamma-GT is more sensitive than AST or ALT for heavy alcohol use and liver injury
- Elevated
Why investigate FBC? And what may this show?
- Testing for:
- Anemia in ALD is likely due to multiple causes such as iron deficiency, gastrointestinal bleeding, folate deficiency, hemolysis, and hypersplenism
- Leukocytosis is likely from alcoholic hepatitis-related leukemoid reaction or associated infection
- Thrombocytopenia may be secondary to alcohol-induced bone marrow suppression, folate deficiency, or hypersplenism
- MCV as a diagnostic tool for alcohol abuse in the absence of vitamin B12 or folic acid deficiency
Why investigate serum electrolytes, magneium and phosphorus? And what may this show?
- Test for:
- Hyponatremia is frequently present in patients with advanced liver cirrhosis
- Hypokalemia and hypophosphatemia are common causes of muscle weakness in ALD
- Hypomagnesemia can cause persistent hypokalemia and may predispose patients to seizures during alcohol withdrawal
Why investigate serum BUN and creatinine? And what may this show?
- Elevated BUN in the presence of normal creatinine suggests active gastrointestinal bleeding; elevated BUN and creatinine is present in hepatorenal syndrome
- Normal or elevated