Alcoholic Liver Disease and Cirrhosis Flashcards
What is the aetiology of alcoholic liver disease?
Alcohol, duh.
- Heavy, prolonged consumption needed to affect damage
- c. 40-80g/day M; 20-40g/day F; for 10-12yrs is sufficient to cause liver damage in the absence of other liver diseases
Other risk factors:
- Drinking outside meal times
- Female sex (due to lower consumption required)
- Genetics - relating to propensity for addiction and metabolism pathways for alcohol
- Hep C
- Smoking
- Vitamin A+E deficiencies
What is the pathophysiology of alcoholic liver disease?
Chronic ethanol intake:
- Acetalhydrate -> NADH production + oxidative stress + lipid peroxidation -> 3 stages
3 stages:
1) Alcoholic steatosis = fatty liver
- c. 90% of drinkers
- Process is reversible
- LFTs can be affected - LOOK LIKE?
2) Alcoholic hepatitis = inflammation and necrosis
- c.25% of drinkers
3) Alcoholic liver cirrhosis = fibrosis of parenchyma
- c.15% of drinkers
What is the pathophysiology of alcoholic liver disease?
Chronic ethanol intake - metabolised by alcohol dehydrogenase into
acetalhydrate -> increased NADH production + oxidative stress + lipid peroxidation -> 3 stages
3 stages:
1) Alcoholic steatosis = fatty liver
- c. 90% of drinkers, can begin after a few days of heavy drinking
- Process is reversible
2) Alcoholic hepatitis = inflammation and necrosis
- c.25% of drinkers
3) Alcoholic liver cirrhosis = fibrosis of parenchyma
- c.15% of drinkers
What is cirrhosis and what causes it? (general)
A diffuse hepatic process involving fibrosis and conversion of normal liver architecture into structurally abnormal nodules
- Hepatic vasculature distorts > increased intrahepatic resistance and portal HTN > varices + renal hypoperfusion (> salt and water retention, fluid overload and increased cardiac output)
- Damage to parenchyma > impaired detox and synthesis
It is the final histological progression of multiple liver diseases:
- *Alcohol
- *Hepatitis B and C
- *Non alcoholic fatty liver disease
- Haemochromatosis
- Primary biliary cirrhosis
- Biliary obstruction
- Autoimmune hepatitis
- Wilsons, porphyria, A1AT-deficiency
- Sarcoidosis
- Budd-Chiari syndrome
- Drugs and toxins e.g. methotrexate, amiodarone, isoniazid
How does alcoholic liver disease present? (by stage)
Fatty liver:
- Asymptomatic
- May show up as an incidental finding on LFTs (mild AST/ALT derangement) or liver USS
Acute alcoholic hepatitis:
- Fever
- Jaundice
- Hepatomegaly +/- tender
- Possible signs of decompensation (ascites, varices, encephalopathy etc. SEE ACUTE LIVER FAILURE DECK)
Cirrhosis:
- A significant portion will be asymptomatic - again showing up incidentally on LFTs/USS (or post mortem)
- Possible signs of decompensation
- CHRONIC SIGNS SEE NEXT CARD
How does cirrhosis present chronically?
Cutaneous features:
- Jaundice
- Scratch marks secondary to pruritus
- Spider naevi (found on trunk and face) and other telangiectasias
- Palmar erythema
- Bruising
- Petechiae or purpura
- Hair loss
- White nails = Terry’s nails (horizontal white bands or a proximal white nail plate = signs of hypoalbuminaemia
- Finger clubbing
- Dupuytren’s contracture
- Caput medusae (veins radiating from umbilicus in portal HTN)
Other:
- Gynaecomastia
- Hypogonadism
Other signs depending on aetiology e.g. Kayser-Fleischer ring in Wilsons
What blood tests are required when assessing alcoholic liver disease? (and cirrhosis more broadly) (think of at least 10)
LFTs:
- AST, ALT, ALP, GGT
- AST:ALT ratio >2:1 suggest alcoholic liver disease; <1 suggest NAFLD/NASH
- GGT raised in active alcoholism
Albumin:
- Hypo in advanced cirrhosis
FBC:
- Occult bleeding may produce anaemia (iron deficient)
- Macrocytosis may suggest alcohol abuse (B12 deficiency)
- Hypersplenism may cause thrombocytopaenia
U+E:
- Hyponatraemia - from increased ADH activity
- Poor renal function may indicate hepatorenal syndrome
B12/folate:
- Often low in alcoholism as malnutrition
Coagulation:
- Sensitive test of liver synthetic function
- PT time is reduced in advanced cirrhosis
Ferritin:
- Low may indicate Fe deficiency from diet or blood loss
- (raised in haemochromatosis)
Viral screen:
- Hep B/C
Fasting glucose/insulin/triglycerides + uric acid levels:
- Should be measured if non-alcoholic steatohepatitis (NASH) suspected
- Gluconeogenesis is one of the last functions to become impaired in the context of liver failure
Anti-mitochondrial Abs in PBC; A1AT levels; ceruloplasmin and copper for Wilsons
What is hepatorenal syndrome?
Rapid deterioration of kidney function in someone with cirrhosis or ongoing hepatic failure
- Usually fatal unless liver transplant
Caused by changes in circulation suppling intestines, affecting blood flow and tone to the kidneys - Can lead to a diuretic resistant ascites
Can be managed with a transjugular intrahepatic portosystemic shunt (TIPS) - to reduce the pressure in the portal vein - whilst awaiting transplant
- Haemodialysis may be required
What imaging is used when assessing alcoholic liver disease/cirrhosis?
Liver USS:
- Surface nodularity - coarse and heterogenous echotexture
- Segmental hypertrophy (caudate and lateral left) and atrophy (posterior left)
- Doppler - signs of portal hypertension e.g. portal vein dilatation, slow flow, ?portal venous thrombosis etc
- Can also be used to guide biopsy for diagnostic histology
Sonoelastography/fibroscan:
- Low amplitude waves propagated through internal organs and vibrations sensed giving a reading of the various densities and stiffnesses present within the organ
CT/MRI
- Less sensitive than above but can be used to find complications, including HCC
What is the Child-Pugh classification system?
Used to estimate prognosis in cirrhosis
Mnemonic = ABCDE
Serum Albumin (g/dL)
- > 35 = 1 point
- 28-35 = 2 points
- <28 = 3 points
Serum total Bilirubin (mg/dL)
- <2 = 1 point
- 2-3 = 2 points
- > 3 = 3 points
INR (Clotting)
- <1.7 = 1 point
- 1.7-2.2 = 2 points
- > 2.2 = 3 points
Ascites (Distension)
- Absent = 1 point
- Controlled medically = 2 points
- Poorly controlled = 3 points
Encephalopathy
- Absent = 1 point
- Controlled medically = 2 points
- Poorly controlled = 3 points
Points = life expectancy
- 5-6 = 15-20yrs
- 7-9 = 4-14yrs
- 10-15 = 1-3yrs
How do you manage alcoholic liver disease and cirrhosis?
STOP DRINKING = MOST IMPORTANT
- Support people with inpatient detox and intensive outpatient alcohol service follow up
Treat any other underlying causes of cirrhosis i.e. infection
Corticosteroids - when severe liver inflammation is present
Ensure adequate nutrition (calories, protein and micronutrients)
- Zn deficiency is common so supplementation may be helpful
- B12/folate
- Iron
Itching:
- Cholestyramine
Osteoporosis:
- Vit D and Ca supplementation +/- bisphosphonates
Prophylactic Abx in those with cirrhosis and UGIB
Vaccination
- Hep A, influenza and pneumococcal
Modification to drug prescribing
Liver transplantation for end stage
Manage any acute complications of decompensation
- Band ligation of varices
- Furosemide and spironolactone for ascites
- TIPS
What are the complications of cirrhosis?
Oesophageal varices:
- Dilatation of oesophageal veins which become prone to bleeding
- Upper endoscopy on Dx then surveillance every 3yrs
Ascites:
- Free fluid in the peritoneal cavity
- Can be treated with diuretics, but may become resistant if advanced liver disease/hepatorenal syndrome
- Also puts patients at risk of spontaneous bacterial peritonitis
Splenomegaly and subsequent thrombocytopaenia
Coagulopathy - from reduced hepatic synthesis of factors II VII IX X ; possible DIC
Hepatocellular carcinoma:
- Most commonly following Hep C cirrhosis
- Patients with cirrhosis should be scanned with USS, CT or MRI 6/12-annually as part of screening
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