Alcoholic Liver Disease Flashcards by Don J

Give examples of organs affected by alcoholism.

Liver

Alcoholic hepatitis

CNS

Gut

Blood

Heart

Reproduction

And trauma due to intoxication

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Alcohol’s effect on liver.

The liver might be completely normal in 50%

Gamma-GT may be severely increased, however this can happen in any type of liver inflammation.

Fatty liver can occur

Cirrhosis

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Explain fatty liver in alcoholism.

It is an acute and reversible condition.

However if it is not managed it can lead to cirrhosis.

Fatty liver can also be seen in obesity, DM and in amiodarone use.

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What can be seen on biopsy of liver cirrhosis due to alcoholic liver disease?

Mallory bodies +/- neutrophil infiltrates

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Alcohol’s effect on the CNS.

Self neglect

Memory and cognition decreases

Cortical atrophy

Retrobulbar atrophy

Fits

Falls

Wide-based gait (ataxic gait)

Neuropathy

Confabulation/Korsakoff’s

Wernicke’s encephalopathy

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How are CNS symptoms treated in alcoholic liver disease?

Giving high potency vitamins (thiamine (B1)) IM .

This may reverse symptoms

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Alcohol’s effect on the gut.

Obesity

Diarrhoea and vomiting

Gastric erosions and peptic ulcers

Varices

Pancreatitis (acute or chronic)

GI cancer

Oesophageal rupture

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Haematological effects of alcohol.

Increased mean cell volume

Macrocytic anaemia

Marrow depression (anaemia)

GI bleeds (anaemia)

Alcohol-associated folate deficiency (anaemia)

Haemolysis (anaemia)

Sideroblastic anaemia

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Alcohol’s effect on the heart.

Arrhythmias

HTN

Cardiomyopathy

Sudden death in binge drinkers

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Alcohol’s effect on reproduction.

Testicular atrophy

Decrease in testosterone and progesterone

Increase in oestrogen

Fetal alcohol syndrome

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Clinical features of foetal alcohol syndrome.

Low IQ

Short palpebral fissure

Absent philtrum

Small eyes

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When does withdrawal start in alcohol dependency?

10-72h after last drink

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Clinical features of withdrawal.

Tachycardia

Low BP

Tremors

Confusion

Fits

Hallucinations (delirium tremens)

This should be considered in any new ward patient with acute confusion

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Management of alcohol withdrawal inpatient.

Admission should only be done if there is complicating or coexisting medical problems.

Checkk BP and TPR every 4h.

First three days give generous chlordiazepoxide (sedative) 10-50mg/6h PO with additional doses PRN.

You should also give vitamins such as thiamine, B12 and folate.

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Prevention management of alcohol.

Alcohol-free beers

Disulfiram

Naltrexone (reduce risk of relapse and frequency)

Acamprosate (reduce frequency)

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Treatment of established alcoholics.

Lifestyle changes, see if there is anything that causes them to drink.

Graceful ways of declining a drink etc…

Alcoholics anonymous

Psychiatry etc…

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50% of patients will relapse after starting treatment, how can this be prevented?

Acamprosate may help intense anxiety, insomnia and cravings.

Disulfiram

Contraindications of acamprosate.

Pregnancy

Severe liver failure

Creatinine >120 micromol/L

Clinical features of alcoholic hepatitis.

Malaise

Increased TPR

Anorexia

Diarrhoea and vomiting

Tender hepatomegaly and jaundice

Bleeding

Ascites

Test findinds in alcoholic hepatitis.

Increased WCC

Decreased platelets

Increased INR

Increased AST

Increased MCV

Increased urea

What suggests severe alcoholic hepatitis?

Jaundice

Encephalopathy

Coagulopathy

Management of alcoholic hepatitis.

Urinary catheter and CVP monitoring may be needed.

Screen for infections +/- ascitic tap.

Stop alcohol consupmtion and treat withdrawal symptoms with chlordiazepoxide and vitamins such as thiamine, B12 and folate.

Give Vit K do reduce the risks of bleeding.

Optimise nutrition

You should still give proteins even if there is severe encephalopathy. This paradoxically prevents encephalopathy but also sepsis and deaths.

Daily monitoring of BLOs and crea + Na+

Steroids might be beneficial in severe cases.

Stepwise process of progression of alcoholic liver disease.

Alcohol related fatty liver disease (reversible process in around 2 weeks after quitting)

Alcoholic hepatitis (mild can still be reversible)

Cirrhosis (permanent but stopping can prevent further damage)

Recommended alcohol consumption

14 units per week for both men and women

Spread evenly over 3 or more days

Not more than 5 units a day

What tool is used to quickly screen for harmful alcohol use?

CAGE questions

Explain CAGE questions

C - Cut down? Ever though you should? A - Annoyed? Do you get annoyed at other commenting your drinking= G - Guilty? Ever feel guilty about drinking? E - Eye opener? Ever drink in the morning to help your hangover/nerves?

Explain AUDIT questionnaire

Alcohol use disorder identification test. 10 questions that gives a score 8 or more gives an indication of harmful use.

Complications of alcohol

Alcoholic liver disease Cirrhosis HCC Alcohol dependence and withdrawal Wernicke-Korskakoff Syndrome Pancreatitis Alcoholic cardiomyopathy

Signs of liver disease

Jaundice Hepatomegaly Spider naevi Palmar erythema Gynaecomastia Bruising Ascites Caput medusae Oesophageal varices Asterixis

Bloods

FBC - Raised MCV LFTs with elevated ALT and AST and particularly raised Gamma-GT Low albumin Elevated bilirubin Clotting with elevated PT time U+Es might be deranged in hepatorenal syndrome

Imaging

Ultrasound Fibroscan Endoscopy for oesophageal varices CT and MRI scans Liver biopsy

What might ultrasound show

Increased echogenicity (fatty changes)

General management

Stop drinking alcohol permanently Consider detoxication regime Nutritional support with vitamins and a high protein diet Steroids in severe alcoholic hepatitis (infection and GI bleeding need to be treated first) Treat complicaitons of cirrhosis Referral for liver transplant in severe disease (must abstain from alcohol for 3 months prior to referral)

Symptoms of alcohol withdrawal

6-12 hours = Tremors, sweating, headache, craving and anxiety 12-24h = Hallucinations 24-48h = Seizures 24-72h = Delirium tremens

Explain delirium tremens

Alcohol stimulates GABA receptors in the brain. The GABA receptors have relaxing effect on the rest of the brain. Alcohol inhibits the glutamate receptors (NMDA) having a further inhibitory electrical activity of the brain. Chronic alcohol -\> GABA system is down-regulated and glutamate system is up-regulated. When alcohol is removed GABA will under-function and glutamate over-functions causing extreme excitability with exess adrenergics activity.

How to manage alcohol withdrawal.

CIWA-Ar tool to score the patient on their withdrawal symptoms and guide treatment. Chlordiazepoxide to calm them down. IV high-dose B vitamins (B12, B1, folate) then lower oral dose thiamine.

What is Wernicke-Korskakoff syndrome?

Alcohol excess leads to B1 def. This leads to Wernicke's encephalopathy first and the Korskakoffs syndrome.

Features of Wernicke's encephalopathy.

Confusion Oculomotor disturbances Ataxia

Features of Korskakoff syndrome

Memory impairment both retrograde and anterograde Behavioural grade

Prognosis of Wernicke-Korskakoff syndrome

Wernicke's encephalopathy is a **medical emergency** and has a high mortality rate if untreated. Korskakoff often **irreversible** and result in patients requiring full time institutional care. Prevention involve thiamine supplementation and abstaining from alcohol.