Alcoholic Liver Disease Flashcards
Give examples of organs affected by alcoholism.
Liver
Alcoholic hepatitis
CNS
Gut
Blood
Heart
Reproduction
And trauma due to intoxication
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
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.
What can be seen on biopsy of liver cirrhosis due to alcoholic liver disease?
Mallory bodies +/- neutrophil infiltrates
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
How are CNS symptoms treated in alcoholic liver disease?
Giving high potency vitamins (thiamine (B1)) IM .
This may reverse symptoms
Alcohol’s effect on the gut.
Obesity
Diarrhoea and vomiting
Gastric erosions and peptic ulcers
Varices
Pancreatitis (acute or chronic)
GI cancer
Oesophageal rupture
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
Alcohol’s effect on the heart.
Arrhythmias
HTN
Cardiomyopathy
Sudden death in binge drinkers
Alcohol’s effect on reproduction.
Testicular atrophy
Decrease in testosterone and progesterone
Increase in oestrogen
Fetal alcohol syndrome
Clinical features of foetal alcohol syndrome.
Low IQ
Short palpebral fissure
Absent philtrum
Small eyes
When does withdrawal start in alcohol dependency?
10-72h after last drink
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
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.
Prevention management of alcohol.
Alcohol-free beers
Disulfiram
Naltrexone (reduce risk of relapse and frequency)
Acamprosate (reduce frequency)
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…
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.
