Gastroenterology Flashcards
Alcoholic liver disease results from the effects of the long term excessive consumption of alcohol on the liver. The onset and progression of alcoholic liver disease varies between people, suggesting that there may be a WHAT to the harmful effects of alcohol on the liver ?
Genetic predisposition
Stepwise process of progression of alcoholic liver disease ?
- ALCOHOL RELATED FATTY LIVER - drinking leads to a build up of fat in the liver (steatosis). If drinking stops this process reverses in around 2 weeks.
- ALCOHOLIC HEPATITIS - Drinking alcohol over a long period causes inflammation in the liver sites. Binge drinking is associated with the same effect. Mild alcoholic hepatitis is usually reversible with permanent abstinence.
- CIRRHOSIS - this is where fibrotic scar tissue replaces healthy tissue in the liver. This is irreversible. Stopping drinking can prevent further damage. Continued drinking has a very poor prognosis.
Recommended alcohol consumption ?
Not to regularly drink more than 14 units per week for both men and women. If drinking 14 units a week this should be spread evenly over 3 or more days and not more than 5 units in a single day.
Government guidelines state that any level of alcohol consumption increases the risk of cancers. Particularly which three ?
Breast, mouth and throat.
CAGE questions ? (what are the used for and what does CAGE stand for)
Used to quickly screen for harmful alcohol use
C - Cut down? Ever though you should?
A - Annoyed? Do you get annoyed at others commenting on your drinking?
G - Guilty? Ever feel guilty about drinking
E - Eye opener? Ever drink in the morning to help your hangover or nerves ?
What is the alcohol use disorders identification test (AUDIT) ?
Was developed by the WHO to screen people for harmful alcohol use. It involves 10 questions with multiple choice answers and gives a score. A score of 8 or more gives indication of harmful use.
Name 6 conditions caused by excessive alcohol use ?
- Alcoholic liver disease
- Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma
- Alcohol dependence and withdrawal
- Wernicke-Korsakoff syndrome (WKS)
- Pancreatitis
- Alcoholic cardiomyopathy
9 signs of liver disease ?
- Jaundice
- Hepatomegaly
- Spider naevi
- Palmar erythema
- Gynaecomastia
- Bruising (due to abnormal clotting)
- Ascites
- Caput medusae (engorged superficial epigastric veins)
- Asterixis (“flapping tremor” in decompensated liver disease)
Blood investigations for alcoholic liver disease and what would these show ?
- FBC - shows raised MCV
- LFTts - shows elevated AST and ALT and particularly raised gamma GT. ALP will be elevated later in the disease. Low albumin due to reduced “synthetic function” of the liver. Elevated bilirubin in cirrhosis
- CLOTTING - shows elevated prothrombin time due to reduced “synthetic function” of the liver (reduced production of clotting factors.
- U&Es - may be deranged in hepatorenal syndrome.
Investigations for alcoholic liver disease (excluding bloods) ?
- US of liver - may show fatty changes early on described as “increased echogenicity”. It can also demonstrate changes related to cirrhosis.
- “FibroScan” - can used to check the elasticity of the liver by sending high frequency sound waves into the liver. It helps assess the degree of cirrhosis.
- Endoscopy - can be used to assess for and treat oesophageal varices when portal HTN is suspected
- CT and MRI scans - can be used to look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites.
- Liver biopsy - can be used to confirm the diagnosis of alcohol related hepatitis or cirrhosis. NICE recommend considering a liver biopsy in pts where steroid treatment is being considered.
General management of alcoholic liver disease (6 bullet points) ?
- Stop drinking alcohol permanently
- Consider a detoxication regime
- Nutritional support with vitamins (particularly thiamine) and a high protein diet
- Steroids improve short term outcomes (over 1 month) in severe alcoholic hepatitis but infection and GI bleeding need to be treated first. Steroids do not improve outcomes over the long term.
- Treat complications of cirrhosis (portal hypertension, varices, ascites and hepatic encephalopathy)
- Referral for liver transplant in severe disease however they must abstain from alcohol for 3 months prior to referral
Alcohol withdrawal symptoms with time scale ?
- 6-12 hrs: tremor, sweating, headache, craving and anxiety
- 12-24 hrs: hallucinations
- 24-48 hrs: seizures
- 24-72 hrs: delerium tremens
What is delirium tremens (include presentation which has 9 bullet points)?
A medical emergency associated with alcohol withdrawal. Alcohol stimulates GABA receptors in the brain. GABA receptors have a relaxing effect on the rest of the brain. Alcohol also inhibits glutamate receptors ( also known as NMDA receptors) having a further inhibitory effect on the electrical activity of the brain.
Chronic alcohol use results in the GABA system becoming up-regulated and the glutamate system being down-regulated to balance the effects of the alcohol. When alcohol is removed from the system, GABA under-functions and glutamate over-functions causing an extreme excitability of the brain with excessive adrenergic activity. This presents as:
- Acute confusion
- Severe agitation
- Delusions and hallucinations
- Tremor
- Tachycardia
- HTN
- Hyperthermia
- Ataxia
- Arrhythmias
Assessment tool used to score pt on their alcohol withdrawal symptoms and guide treatment ?
CIWA-Ar (clinical institute withdrawal assessment)
Treatment for alcohol withdrawal ?
- Chlordiazepoxide (“Librium”) - is a benzodiazepine used to combat the effects of alcohol withdrawal. Diazepam is a less commonly used alternative. It is given orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g. 10-40mg every 1-4 hrs). This is continued for 5-7 days.
- IV high dose B vitamins - this should be followed by regular lower dose oral thiamine. This is used to try and prevent Wernicke-Korsakoff syndrome.
How can alcoholism cause Wernicke-Korsakoff syndrome ?
Alcohol excess leads to thiamine (vitamin B1) deficiency. Thiamine is poorly absorbed in the presence of alcohol. Alcoholics tend to have poor diets and rely on the alcohol for their calories. Wernicke’s encephalopathy comes before Korsakoffs syndrome. These result from thiamine deficiency.
Features of Wernicke’s encephalopathy (3 points) ?
- Confusion
- Opthalmoplegia
- Ataxia (difficulties with coordinated movements)
Features of Korsakoffs syndrome (2 points) ?
- Memory impairment (retrograde and anterograde)
- Behavioural changes
Delirium tremens is a medical emergency with a mortality rate of what if left untreated ?
35%
Is Wernicke’s encephalopathy a medical emergency and does it have a high or low mortality rate if untreated ?
Yes it is a medical emergency and it has a high mortality rate if untreated
Is Korsakoffs syndrome reversible ? What does it result in ? What do prevention and treatment involve
- It’s often irreversible
- Results in pts requiring full time institutional care
- Prevention and treatment involve thiamine supplementation and abstaining from alcohol.
Brief summary of liver cirrhosis ?
It’s the result of chronic inflammation and damage to liver cells. When the liver cells are damaged they are replaced with scar tissue (fibrosis) and nodules of scar tissue form within the liver. The fibrosis affects the structure and blood flow through the liver, which causes increased resistance in the vessels in to the liver. This is called portal hypertension.
Four most common causes of liver cirrhosis ?
Alcoholic liver disease
Non alcoholic fatty liver disease
Hepatitis B
Hepatitis C
7 less common causes of liver cirrhosis ?
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Haemochromatosis
- Wilsons disease
- Alpha-1 antitrypsin deficiency
- Cystic fibrosis
- Drugs (e.g. amiodarone, methotrexate, sodium valproate)