E2: Alcohol Related And Liver Cancer Flashcards
What are the 3 patterns of injury associated with ALD?
1) fatty liver
2) Alcoholic hepatitis
3) Chronic hepatitis with fibrosis or cirrhosis
What are the risk factors for ALD?
- Daily drinking above the threshold of 1/day (women) or 2/day for men
- women develop more severe ALD at lower doses with shorter duration
- Increased BMI
- Genetic factors
- Co-existing CLD
- Smoking
Is fatty liver reversible?
Yes, reversible with abs intense from alcohol after about 4-6 weeks
What is the treatment of fatty liver?
Lifestyle modifications and alcohol cessation
What is alcohol related hepatitis?
-Inflammation of the liver characterized by necrosis and fibrotic scarring, most likely to occur in chronic or current heavy alcohol consumption
What are the clinical features of alcohol hepatitis?
- fever, leukocytosis
- hepatic encephalopathy
- spider angiomas
- jaundice
- hepatosplenomegaly with liver tenderness
- edema
- ascites
What finding on liver histology is consistent with Alcoholic hepatitis?
Mallory Denk body and neutrophilic lobular inflammation
How is a definite diagnosis of alcoholic hepatitis made?
Clinical diagnosis with liver biopsy confirmation
What is the management of alcoholic hepatitis?
- Hospitalize with severe AH
- in severe AH, treat with steroids with patients that are eligible and without contraindications
- Discontinue alcohol, complete abstinence is essential in all patients
What is the most important factor is improving survival for patients with alcoholic hepatitis?
Discontinue alcohol use
What is hepatic encephalopathy?
-Failure of the liver to detoxify noxious agents of gut origin because of hepato-cellular dysfunction and portosystemic shunting
What is the best known neurotoxin that can precipitate hepatic encephelopathy?
Ammonia
How is hepatic encephalopathy treated?
Lab tulles for acute overt hepatic encephalopathy and secondary prophylactic therapy for an indefinite period of time
What are are the symptoms of grade I HE?
Changes in behavior, mild confusion, slurred speech, disordered sleep pattern
What are the signs of grade II HE?
Lethargy, moderate confusion, asterixsis
What are the symptoms of grade III HE?
Marked confusion, incoherent speech, and sleeping but can arouse
What are the symptoms of Grade IV HE?
Coma and unresponsive to pain
What is a stroop test used for?
The stroop test is a brief cognitive screening tool that evaluates psychomotor speed and cognitive flexibility
-Able to diagnose minimal hepatic encephalpathy with excellent sensitivity and specificity
What medications are given to treat hepatic encephelopathy?
Lab tulles and rifaximin
What does the Lillie model do?
Calculates the likelihood of patients response to steroids
What does an Maddreys Discriminant function (MDF) ≥32 predict?
Predicts 30-50 mortality at 28 days
What does the model for End stage liver disease (MELD) do?
Calculates mortality rate in 90 days
What is cirrhosis?
-Widespread destruction and regeneration of liver tissue and a marked increase in fibrotic connective tissue
What is compensated cirrhosis characterized by?
- Portal pressure <10
- Median survival ~ 12 years
- Clinical manifestations splenomegaly, thrombocytopenia, leukopenia, anemia, and AST elevation
What is decompensated cirrhosis characterized by?
- Increased portal pressure, decreased Liver function
- medial survival is ~2 years
- portal HTN, Porto-systemic shunting
What is portal Hypertension?
- Increased pressure within the portal venous system, commonly seen in decompensated cirrhosis and acute alcoholic hepatitis
- Increased pressure promotes collateral circulation
What are the 3 possible sites of obstruction to flow in portal hypertension?
- Pre-hepatic: portal vein thrombosis
- Intrahepatic: Cirrhosis
- Post hepatic: CHF,
What is the treatment for ascites?
- adherence to less then 2g sodium per day
- Lasix or spironolactone
- fluid restriction
How much albumin do you need to replace when performing a paracentesis?
6-8 grams of albumin for each liter >5 removed to prevent kidney injury
When should you refer for liver transplant if a patient has cirrhosis?
If decompensated cirrhosis or a MELD ≥15
What is the prognosis for alcoholic fatty liver?
-Complete resolution may occur if alcohol is stopped for 4-6 weeks
What is the prognosis for alcoholic hepatitis?
Prognosis depends on severity. Mild cases are often reversible. Need to discontinue alcohol
What are the possible complications of cirrhosis?
- Portal HTN
- Spontaneous bacterial peritonitis
- Hepatic encephalopathy
- Hepatomegaly syndrome
What is the diagnostic criteria of Hepatorenal syndrome?
- Signs of decompensated liver disease
- absence of shock
- renal impairment
- no improvement with correction of volume status and albumin for ≥ 2 days
- absence of other causes of AKI
What are the clinical features of hepatorenal syndrome?
-Progressive rise in serum creatinine
-azotemia
-very low urine sodium concentration
-
What is type 1 hepatorenal syndrome?
- Rapidly and progressive renal failure with severe multi organ failure
- median survival is ≤4 weeks
What is type 2 hepatorenal syndrome?
Associated with refractory ascites
-median survival is 6 months
How Is hepatorenal syndrome prevented?
- use albumin IV with large volume paracentesis
- Protect against GI bleeding with EGD surveillance or beta blocker use
- No NSAIDs
- SBP prophylaxis with ABX with Cipro or Bactrim
What are the 4 types of benign liver lesions that do not require intervention?
- Cavernous hemangioma <4cm
- focal nodular hyperplasia
- Simple cyst and asymptomatic
- focal fatty change/sparing
What are the benign liver lesions that require management?
- Adenoma (malignant potential)
- Liver abscess
- inflammatory pseudo tumor
- atypical/complex cyst and large symptomatic cysts
What are the 3 malignant liver lesions?
- Mets
- Lymphoma
- Primary liver neoplasm
What are the 3 types of primary liver neoplasm?
- HCC
- Cholangiocarcinoma
- other rare tumors
What are neoplasms arising from parenchyma cells called?
HCC
What are neoplasms arising from ductal cells called?
Cholangiocarcinomas
What patients have a high risk for HCC?
Cirrhotic patients and non-cirrhotic Hep B
What lab is often elevated in HCC?
Alpha fetoprotein
