Patient Presentation, Tests and Alcoholism Flashcards
What are the important risk factors?
o Alcohol intake o Drug use o Travel o Blood transfusions o Tattoos o Unprotected sexual activity
What is important to identify on examination?
o Fever, cachexia o Hepatic encephalopathy / flap o Signs of chronic liver disease o Scars off surgery – cholecystectomy o RUQ / epigastric pain o Hepatomegaly o Splenomegaly and ascites
What is cachexia?
Extreme weight loss and muscle wasting
When should you suspect cancer in a patient?
- Looking cachectic
- Have lymphadenopathy
diseased lymphnodes causing them to become enlarged and unequal in size - Hard, craggy liver edge
- Unintentional weight loss
What is the most common cancer in this region of the abdomen?
Carcinoma of the head of the pancreas
When should you exclude carcinoma of the head of the pancreas in patients?
- > 40 yrs
- Have painless, obstructive jaundice
What is liver cancer usually caused by?
- Metastases from other primary cancers (lung cancer)
When would you suspect cholangiocarcinoma (cancer of the gallbladder)?
When you can palpate the gallbladder on examination
What condition is primary hepatocellular cancer is more common in?
Cirrhosis
How would you test for primary hepatocellular cancer?
- Ultrasound
- Raised Alpha-fetoprotein (AFP)
What are liver function tests?
- INR / Prothrombin time
- Albumin
What are liver enzyme tests?
- Transaminases (AST, ALT)
- Alkaline phosphatase
- GGT (Gamma-GT)
What is prothrombin time / INR?
A laboratory measurement of how long it takes blood to form a clot. It is used to determine the effects of oral anticoagulants on the clotting system.
What does a rise in ALT, AST»_space; rise in alkaline phosphate indicate?
Hepatocellular damage
What does a rise in ALT, AST «_space;rise in alkaline phosphate indicate?
Obstructive cause
When would you look at gamma-GT (GGT)?
When there is a doubt in the tissue of origin of AST
What are transaminases?
Enzymes involved with amino acid metabolism in the liver.
They are released by hepatocytes when the liver becomes damaged.
What is the clinically relevant subcellular localisation of AST?
- Found in cytoplasm and mitochondria
- Is abundant in muscle and hepatocytes
What is the clinically relevant subcellular localisation of ALT?
- Found in cytoplasm
- Predominatly hepatic
Where is alkaline phosphatase found?
- Liver - 55%; in hepatocytes next to biliary canaliculi
- Bone - 45%; in osteoblasts
- Gut - 5%
- Kidney
- Placenta
What could a raised alkaline phosphatase indicate?
- Hepatobiliary disease
Cholestasis
Hepatocyte disease
- Bone disease
Paget's Disease
Osteomalacia and rickets
Renal osteodystrophy
Bone metastases
Primary bone tumour
Recent fracture
Growing child - especially at puberty
- Pregnancy
- MalignancyWhat are the infective causes that can make LFTs abnormal?
o Epstein Barr virus
o Cytomegalovirus (CMV)
o Hepatitis A, B or C
What are the lifestyle causes that can make LFTs abnormal?
o Obesity
o Alcohol excess
o Diabetes mellitus
What are the drug causes that can make LFTs abnormal?
o Anti-epileptics o Methotrexate o Rifampicin o Flucloxacillin o Paracetamol overdose
What are the extra-heaptic (obstructive) causes that can make LFTs abnormal?
o Carcinoma of the pancreas
o Gallstones
What are the autoimmune causes that can make LFTs abnormal?
o Autoimmune hepatitis
o Primary sclerosing cholangitis
o Primary biliary cholangitis
What are the hereditary causes that can make LFTs abnormal?
o Wilson’s disease
o Alpha-1-antitrypsin deficiency
o Hereditary haemochromatosis
What is an alcohol unit?
1 unit = 10ml or 8g of pure alcohol
What are the recommendations for drinking alcohol?
14 units per week, best spread out over 3+ days. Pregnant women shouldn’t be drinking at all
What patients experience alcohol withdrawals?
- In patients who are alcohol dependent and who have stopped or reduced their alcohol intake within hours or days of presentation.
- Symptoms typically begin 6-12 hours after the patient’s last alcoholic drink
What are delirium tremens?
Acute confusional state that results when someone who drinks excess alcohol daily, suddenly stops drinking
What can happen if delirium tremens are left untreated?
- Seizures
- Death
What are the key diagnostic factors of alcoholism?
• CAGE questionnaire • AUDIT Questionnaire o Score >8 gives an indication of harmful alcohol use • Anxiety • Nausea and vomiting • Autonomic dysfunction: o Tremor o Tachycardia o Sweating o Palpitations • Insomnia
What is the CAGE questionnaire?
o C: Have you felt the need to CUT down on your drinking?
o A: Have you ever felt ANNOYED by someone criticising your drinking?
o G: Have you ever felt bad or GUILTY about your drinking?
o E: Have you ever had an EYE-OPENER - a drink first thing in the morning to steady your nerves?
How do you treat delirium tremens?
- 1st line: oral lorazepam
- Then: parenteral lorazepam or haloperidol
What is the management of alcohol withdrawals?
- 1st line: Chlordiazepoxide
- Then: Diazepam
When would you give parenteral thiamine followed by oral thiamine for alcohol withdrawals?
To prevent Wernicke-Korsakoff syndrome in people who are:
- Malnourished
- At risk of malnourishment
- Have decompensated liver disease
What are the complications of alcoholism?
- Alcoholic liver disease
- Cirrhosis and complications of cirrhosis including hepatocellular carcinoma
- Alcohol dependence and withdrawal
- Wernicke-Korsakoff Syndrome (WKS)
- Pancreatitis
- Alcoholic cardiomyopathy
What is Wernicke-Korsakoff Syndrome (WKS)?
Thiamine (vitamin B1) deficiency
- Thiamine is poorly absorbed in the presence of alcohol
- Alcoholics tend to have poor diets
