Week 15 - Alcoholic hep, hep and drug overdose Flashcards by Rosa Birt

what is the step wise progression of alcohol-related liver disease

alcoholic fatty liver (hepatic steatosis)
alcoholic hepatitis
cirrhosis

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what is step 1 - alcoholic fatty liver

drinking leads to a build up of fat in the liver. this process is reversible with abstinence

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what is step 2 - alcoholic hepatitis

drinking alcohol over a long period causes inflammation in the liver cells. binge drinking is associated with the same effect. mild alcoholic hepatitis is usually reversible with permanent abstinence

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what is step 3 - cirrhosis

cirrhosis is where the functional liver tissue is replaced with scar tissue. it is irreversible.

stopping drinking can prevent further damage. continued drinking has a very poor prognosis

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what is binge drinking defined as in men and women

in women, 6 units or more and in men, 8 units or more

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what are the examination findings with excess alcohol

Smelling of alcohol
Slurred speech
Bloodshot eyes
Dilated capillaries on the face (telangiectasia)
Tremor

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what are the blood test results that suggest alcohol related liver disease

Raised mean cell volume (MCV)

Raised alanine transaminase (ALT) and aspartate transferase (AST)

AST:ALT ratio above 1.5 particularly suggests alcohol-related liver disease

Raised gamma-glutamyl transferase (gamma-GT) (particularly notable with alcohol-related liver disease)

Raised alkaline phosphatase (ALP) later in the disease

Raised bilirubin in cirrhosis

Low albumin due to reduced synthetic function of the liver

Increased prothrombin time due to reduced synthetic function of the liver (reduced production of clotting factors)

Deranged U&Es in hepatorenal syndrome

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what is ultrasound used for in alcoholic liver

may show early fatty changes with increased echogenicity.

later, it can show changes related to cirrhosis. ultrasound is used to screen for hepatocellular carcinoma in patients with cirrhosis

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what can be used to assess the elasticity of the liver using high frequency sound waves

transient elastography (fibroscan)

it helps determine the degree of fibrosis (scarring)

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what can be used to assess for and treat oesophageal varices when portal hypertension is suspected

endoscopy

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what can be used to look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites

CT and MRI

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what can be used to confirm the diagnosis of alcohol related hepatitis or cirrhosis

liver biopsy

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what is the one general principle to manage alcohol related disease

stop drinking alcohol permanently

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what vitamins are given to people with liver disease

thiamine - vitamin B1 and high protein diet

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what may be used to reduce inflammation in severe alcoholic hepatitis to improve short term outcomes

corticosteroids

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how long is alcohol abstenince require for a liver transplant

6 months

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what is alcohol dependence

Alcohol dependence involves daily alcohol consumption, strong urges and cravings for alcohol, difficulty controlling consumption, tolerance to the effects of alcohol and withdrawal symptoms when stopping.

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what is the CAGE questionaire

C – CUT DOWN? Do you ever think you should cut down?

A – ANNOYED? Do you get annoyed at others commenting on your drinking?

G – GUILTY? Do you ever feel guilty about drinking?

E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?

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what is the AUDIT questionnaire

The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organisation to screen people for harmful alcohol use. It involves 10 questions with multiple-choice answers and gives a score

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what score on the AUDIT indicates harmful use

score of 8 or more

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what are the alcohol withdrawal symptoms at different time periods

6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens

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what is delirium tremens

a medical emergency associated with alcohol withdrawal

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how does alcohol work in the brain

it is a depressant. it stimulates GABA receptors that have a relaxing effect on the brain.

it also inhibits glutamate receptors causing further relaxing effect on the electrical activity of the brain

what does chronic alcohol use result in in the brain

the GABA system becoming down regulated and glutamate system becoming up-regulated to balance the effects of alcohol

what happens when alcohol is removed

the GABA system under functions and the glutamate system over functions, causing extreme excitability of the brain and excessive adrenergic activity

how does delirium tremens present

Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hypertension Hyperthermia Ataxia (difficulties with coordinated movements) Arrhythmias

what tool can be used to score the patient on their withdrawal symptoms and guide treamtne t

the CIWA-Ar tool

what is used to combat the effects of alcohol withdrawal

Chlordiazepoxide (Librium

what is used to prevent Wernicke-Korsakoff syndrome

high dose B vitamins (Pabrinex) followed by long term oral thiamine

what is Wernicke Korsakoff syndrome

alcohol excess leads to thiamine (vit b1) deficiency. this leads to Wernicke’s encephalopathy and Korsakoff syndrome.

what are the features of Wernicke’s encephalopathy include:

Confusion Oculomotor disturbances (disturbances of eye movements) Ataxia (difficulties with coordinated movements)

Features of Korsakoff syndrome include:

Memory impairment (retrograde and anterograde) Behavioural changes

what are the mortality features of both of these

Wernicke’s encephalopathy is a medical emergency with a high mortality rate. Korsakoff syndrome is often irreversible and results in patients requiring full-time institutional care. Prevention and treatment involve thiamine supplementation and abstaining from alcohol.

what is the single most common cause of acute liver injury in the western world

paracetamol overdose

when to symptoms and signs of paracetamol overdose occur

not until 24 hours after ingestion

what are the signs and symptoms of paracetamol overdose

Nausea / vomiting Abdominal pain RUQ tenderness Hepatic necrosis causes: Jaundice, RUQ pain (from hepatic necrosis) Encephelopathy Hypoglycaemia Renal failure Oliguria Metabolic Acidosis Often asymptomatic, until 24-72 hours after when acute liver failure occurs

what are the most important tests to carry out in paracetamol overdose

Paracetamol level and ALT are the most important tests

what is the paracetamol test

Paracetamol (+ salicylate) level – Only accurate if >4 hours after ingestion Paracetamol level is only useful for the purposes of the nomogram if taken >4 hours after ingestion In cases of massive overdose – repeat the paracetamol level 2 hours before completion of acetylcysteine – if it remains >10mg/L – continue acetylcysteine

what are the LFT's in paracetamol overdose

ALT is the most important LFT in paracetamol overdose This should be taken at presentation and repeat 2 hours before the completion of acetylcysteine dose. If >50U/L – then continue acetylcysteine

what is the graph used to estimate the need for treatment

normogram

when should the nomogram only be used

if all the following are met - Time of ingestion known - Acute overdose (not staggered) - Immediate release paracetamol has been taken (not prolonged release) - Paracetamol level taken >4 hours since ingestion

patients with what level according to the nomogram should be given modified acetylcysteine regimens

patients with levels more than double the nomogram line

what is the management if <8 hours after ingestion

Not suitable in many instances. Give 50mg activated charcoal orally if: - <2hrs (most effective if <1hr) after overdose - Can be considered up to 4hrs if >30g paracetamol ingested - Consider in children with a dose of 1g/Kg up to 50g Awake, co-operative adult Dose greater than 30g It is very unpleasant! N-acetylcystine (aka NAC) promotes conjugation of circulating paracetamol. Greatest effect if given <12 hours after ingestion

what is N-acetylcystine usually administered with

5% dextrose

what is the management if >8 hours after ingestion

Give acetylcystiene if >12g or >150mg/Kg has been ingested, regardless of current plasma level (don’t wait for blood result)

when should liver transplant be considered in paracetamol overdose

INR >3 at 48 hours post ingestion or 4.5 at any time Oliguira or creatinine > 200 umol/L Persistent acidosis (pH < 7.3), or lactate >3 Systolic BP <80mmHg despite resuscitation Hypoglycaemia, severe thrombocytopenia or encephelopathy GCS <15 not associated with sedative ingestion

what is autoimmune hepatitis

a rare cause of chronic hepatitis. it appears to occur due to a combination of genetic and environmental factors

what are the two types of autoimmune hepatitis

type 1 and type 2

what is type 1 autoimmune hepatitis

typically affects women in their late forties or fifties. it presents around or after menopause with fatigue and features of liver disease on examination. it takes a less acute course than type 2

what is type 2 autoimmune hepatitis

usually affects children and young people, more commonly girls. it presents with acute hapatitis with high transaminases and jaundice

what will investigations into autoimmune hepatitis show *(LFT's)

Investigations will show high transaminases (ALT and AST) and minimal change in ALP levels (a “hepatitic” picture). Raised immunoglobulin G (IgG) levels are an important finding.

what are the autoantibodies found in type 1 autoimmune hepatitis

Anti-nuclear antibodies (ANA) Anti-smooth muscle antibodies (anti-actin) Anti-soluble liver antigen (anti-SLA/LP)

what are the autoantibodies found in type 2 autoimmune hepatitis

Anti-liver kidney microsomes-1 (anti-LKM1) Anti-liver cytosol antigen type 1 (anti-LC1)

what is found in a liver biopsy in autoimmune hepatitis

Liver biopsy forms part of the diagnosis. Key histology findings are interface hepatitis and plasma cell infiltration.

what is the management of autoimmune hepatitis

treatment is with high dose steroids (prednisolone) other immunosuppresants such as azathioprine are used