GIS Case 2: Alcoholic Liver Disease

Question 1

Anatomy and function of Liver and Biliary tract

Answer 1

See lecture

***Only organ to synthesise serum Albumin, coagulation factors (1, 2, 5, 7, 9)

Bile system (Liver + Gall bladder + Bile ducts):
Bile canaliculi —> Canals of Hering —> Interlobular bile duct —> Intrahepatic bile duct —> L/R hepatic ducts —> Common hepatic duct —> exit liver —> Cystic duct —> Common bile duct (joined by Pancreatic duct) —> Ampulla of Vater —> Duodenum

Question 2

Physiology of bile formation and excretion

Answer 2

See lecture

• Hepatocytes —> Bile salt
• Secretin —> Ductal epithelial cells —> HCO3
• CCK —> Gallbladder contraction

Question 3

Causes of Jaundice

Answer 3

Unconjugated hyperbilirubinaemia:

1. Overproduction of bilirubin
   - ***Haemolysis
2. Reduced bilirubin uptake
   - ***Reduced hepatic blood flow —> Impaired bilirubin delivery to liver
   - Disorders of internalisation of bilirubin by hepatocytes
3. Impaired bilirubin conjugation (Decreased UDP-Glucuronosyltransferase activity)
   - ***Gilbert syndrome

Conjugated hyperbilirubinaemia:

1. ***Biliary obstruction / Extrahepatic cholestasis
   - bilirubin transported back to plasma
2. ***Intrahepatic cholestasis
   - Viral hepatitis
   - Alcoholic hepatitis
   - Drugs, toxins
3. ***Hepatocellular injury
   - Cirrhosis
   - Neoplasm e.g. HCC
   - Infection
   - Acute ischaemia
   —> accompanied by AST / ALT elevation

Question 4

Clinical manifestations of upper GI bleeding

Answer 4

1. Haematemesis
   - fresh blood
   - coffee-ground
2. Melena

Question 5

Pathogenesis of cirrhosis

Answer 5

See lecture

Scar tissue replace normal parenchyma

• ***Distortion of hepatic architecture
• **Regenerative nodules surrounded by **Fibrous CT

Question 6

Harmful effects of alcohol

Answer 6

1. Hypertension
2. CVS disease
3. Liver disease
4. Pancreatitis, Gastritis, Esophagitis
5. Psychiatric disorder

Question 7

***Importance of History taking in management of alcohol-related liver disease

Answer 7

• chief complaint
• family history
• medical history
• drug history
• social history
• travel history

Question 8

***Importance of Physical examination in management of alcohol-related liver disease

Answer 8

1. Hypotension —> compensated by Tachycardia
2. Pallor + Jaundice —> caused by Portal hypertension —> Splenomegaly —> ***Haemolytic anaemia
3. Bilateral ankle edema —> liver cannot produce ***Albumin —> ↓ osmolarity of blood —> ECF cannot drain into blood vessel
4. Spider naevi —> ∵ Liver cannot metabolise estrogen —> ***↑ Estrogen in blood —> Vascular lesions with central arteriole surrounded by smaller vessels
5. Dupuyten’s contracture: >=1 fingers permanently flexed —> associated with alcohol intake
6. ***Flapping tremor —> Hepatic encephalopathy
7. Distended abdomen
8. Hepatomegaly —> may be present in cirrhosis —> **Firm + **Nodular consistency
9. ***Ascites
10. Splenomegaly —> ∵ Portal hypertension
11. ***Shifting dullness —> Ascites (Fluid go from interstitial space into peritoneal cavity)
12. Per-rectal examination —> Melena (Upper GI bleeding)

Question 9

***Importance of Investigation in management of alcohol-related liver disease

Answer 9

1. CBC
   - Low Hb, platelet —> Splenomegaly —> Sequestration
   - Urea —> GI bleeding —> digestion of blood —> high blood urea nitrogen levels
   - Low albumin —> cause Ascites
   - High Total Bilirubin —> Hyperbilirubinaemia
   - LFT
   —> ALT, AST —> usually AST < ALT, if AST:ALT > 2:1 —> suggest ***Alcoholic liver disease, particularly if GGT elevated
   —> ALP (high level suggest biliary obstruction)
   —> GGT (high level suggest biliary obstruction)
2. Clotting profile
   - PT —> prolonged (∵ ↓ coagulation factors production)
   - INR
   - APTT
3. Hepatitis serology
   - HBsAg -ve: no chronic Hep B infection
   - Anti-HCV -ve: no Hep C infection
4. Ultrasound
   - Hepatomegaly with irregular outline and fatty change
   - Splenomegaly
   - Ascites

Question 10

Social impact of harmful use of alcohol and underage drinking

Answer 10

1. Stop people from drinking at earlier age

2. 1 in 6 adults who drank in past year have a drinking habit before 18 yo

Question 11

Public health policies to tackle alcohol-related health problems

Answer 11

1. Organisation in HK to help quit drinking
   - Alcohol treatment service from Castle Peak Hospital
   - Alcohol anonymous group meeting
2. Alcohol prevention campaign in secondary school
3. Law
4. Tax
5. Drinking driving penalty
6. Advertisement restriction
7. Education to parents

Question 12

Ethical principles in liver transplantation for patients with alcohol-related liver disease

Answer 12

• Transplant hospital often require patients to demonstrate 6 months of sobriety before allowed to register
• Beneficence: Best interest of patient
• Justice: Fair distribution of health resources?
• Principles of medical ethics should override moral positions