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Y3 Medicine: Gastroenterology and Hepatology > Alcoholic Liver Disease > Flashcards

Alcoholic Liver Disease Flashcards

1
Q

What are the 3 stages of alcoholic liver disease (ALD)?

A

3 stages of liver damage:

  1. Fatty liver (steatosis)
  2. Alcoholic hepatitis (inflammation and necrosis)
  3. Alcoholic liver cirrhosis
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2
Q

Briefly describe the pathophysiology of ALD

A

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.

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3
Q

What risk factors are associated with ALD?

A
  • Prolonged and heavy alcohol consumption
  • Hepatitis C
  • Female sex
  • Cigarette smoking
  • Obesity
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4
Q

What are the signs of ALD?

A
  • Hepatomegaly
  • Haematemesis and malene
  • Venous collaterals
  • Splenomegaly
  • Hepatic mass
  • Jaundice
  • Palmar erythema
  • Cutaneous telangiectasia
  • Asterixis
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5
Q

What are the symptoms of ALD?

A
  • Abdominal pain (RUQ)
  • Weight loss or weight gain
  • Fatigue
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6
Q

What investigations should be ordered in ALD?

A
  • 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
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7
Q

Why investigate serum AST and ALT? And what may this show?

A
  • AST and ALT is elevated in ALD when alcohol use >50 g/day
  • Elevated
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8
Q

Why investigate serum AST:ALT ratio? And what may this show?

A
  • 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
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9
Q

Why investigate serum alkaline phosphatase? And what may this show?

A
  • If elevated may represent cholestasis associated with ALD
  • Normal or elevated
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10
Q

Why investigate serum bilirubin? And what may this show?

A
  • 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
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11
Q

Why investigate serum albumin and protein? And what may this show?

A
  • Low albumin reflects impaired synthetic function of the liver
  • Low
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12
Q

Why investigate serum gamma glutamyl transferase (gamma-GT)? And what may this show?

A
  • Gamma-GT is more sensitive than AST or ALT for heavy alcohol use and liver injury
  • Elevated
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13
Q

Why investigate FBC? And what may this show?

A
  • 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
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14
Q

Why investigate serum electrolytes, magneium and phosphorus? And what may this show?

A
  • 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
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15
Q

Why investigate serum BUN and creatinine? And what may this show?

A
  • Elevated BUN in the presence of normal creatinine suggests active gastrointestinal bleeding; elevated BUN and creatinine is present in hepatorenal syndrome
  • Normal or elevated
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16
Q

Why investigate serum prothrombin time (PT) and INR? And what may this show?

A
  • Useful to evaluate synthetic function of the liver. An elevated PT/INR indicates advanced liver cirrhosis or liver failure in ALD patients. Elevated PT has prognostic utility in ALD patients.
  • Normal or prolonged
17
Q

Why investigate using hepatic ultrasound? And what may this show?

A
  • Ultrasound should be performed among patients with harmful alcohol use. It is also used to screen for hepatocellular carcinoma (HCC) every 6 to 12 months in ALD patients with cirrhosis.
  • May show hepatomegaly, fatty liver, liver cirrhosis, liver mass, splenomegaly, ascites, evidence of portal hypertension.
18
Q

Briefly describe the treatment for ALD

A
  • Alcohol abstinence and alcohol withdrawal management
  • Plus:
    • Weight reduction and smoking cessation
    • Nutritional supplementation and multivitamins
    • Immunisation
  • Adjunct:
    • Corticosteroids
    • Sodium restriction and diuretics
19
Q

Briefly describe the treatment for alcohol abstinence and alcohol withdrawal management in ALD

A

Measures include alcohol abstinence counseling, brief intervention psychotherapy, Alcoholics Anonymous, alcohol rehabilitation programs, and behavior modification for cessation of alcohol, smoking, and drug use. Also close monitoring for, and treatment of, symptoms of alcohol withdrawal.

Benzodiazepines are the most commonly used drugs to treat alcohol withdrawal syndrome. Long-acting benzodiazepines (e.g. diazepam) provide greater protection against seizures and delirium; shorter-acting benzodiazepines (e.g. oxazepam, lorazepam) are safer in older adults and those with hepatic dysfunction. High doses of benzodiazepines may trigger or worsen hepatic encephalopathy.

20
Q

Briefly describe the nutritional supplementation and multivitamin treatment in ALD

A

The prevalence of malnutrition is extremely high in ALD.

Guidelines recommend evaluation of nutritional status, with consideration for nutritional supplementation to ensure sufficient caloric intake and to correct specific deficits. Nutritional therapy should be instituted during hospitalizations for acute decompensation of ALD, including calories, vitamins, and micronutrients (including zinc).

Thiamine and other vitamin supplements should be considered if necessary.

21
Q
A
22
Q

When will a patient with ALD be considered for liver transplantation?

A

Patients with end-stage ALD should be considered for liver transplantation. Patients with ALD must be screened for alcohol-related comorbid disease, and are required by most transplant centres to have at least a 6-month period of confirmed abstinence.

23
Q

What complications are associated with ALD?

A
  • Hepatic encephalopathy
  • Portal hypertension
  • GI bleeding
  • Coagulopathy
  • Renal failure
24
Q

What differentials should be considered for ALD?

A
  1. Hepatitis B
  2. Hepatitis C
  3. Cholecystitis
25
Q

How does ALD and hepatitis B differ?

A
  • Differentiating signs and symptoms:
    • Often asymptomatic
    • History may reveal high-risk behaviour
    • May present as acute hepatitis B infection in adults and sometimes can be fatal from complications such as acute liver failure
    • Patients with chronic hepatitis B may develop complications such as cirrhosis, hepatocellular carcinoma, or liver failure
  • Differentiating investigations: serum test positive for hepatitis B surface antigen (HBsAg), hepatitis B virus DNA or anti-hepatitis B core antigen-IgM antibody
26
Q

How does ALD and hepatitis C differ?

A
  • Differentiating signs and symptoms:
    • History may reveal high-risk behaviour (e.g., illicit injection drug use)
    • Most patients are asymptomatic
    • In advanced disease, patients exhibit signs and symptoms related to chronic liver injury from hepatitis C such as jaundice, ascites, spider angiomata, and constitutional complaints
  • Differentating investigations: serum test positive for anti-hepatitis C virus antibody and hepatitis C virus RNA PCR
27
Q

How does ALD and cholecystitis differ?

A
  • Differentiating signs and symptoms:
    • Acute right upper quadrant abdominal pain, with positive Murphy’s sign (pain with inspiration beneath palpation at costal margin)
  • Differentiating investigations: ultrasound of gallbladder is the initial test

Y3 Medicine: Gastroenterology and Hepatology (22 decks)

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