Week 15 - Alcoholic hep, hep and drug overdose

Question 1

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

Answer 1

1. alcoholic fatty liver (hepatic steatosis)
2. alcoholic hepatitis
3. cirrhosis

Question 2

what is step 1 - alcoholic fatty liver

Answer 2

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

Question 3

what is step 2 - alcoholic hepatitis

Answer 3

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

Question 4

what is step 3 - cirrhosis

Answer 4

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

Question 5

what is binge drinking defined as in men and women

Answer 5

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

Question 6

what are the examination findings with excess alcohol

Answer 6

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

Question 7

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

Answer 7

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

Question 8

what is ultrasound used for in alcoholic liver

Answer 8

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

Question 9

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

Answer 9

transient elastography (fibroscan)

it helps determine the degree of fibrosis (scarring)

Question 10

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

Answer 10

endoscopy

Question 11

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

Answer 11

CT and MRI

Question 12

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

Answer 12

liver biopsy

Question 13

what is the one general principle to manage alcohol related disease

Answer 13

stop drinking alcohol permanently

Question 14

what vitamins are given to people with liver disease

Answer 14

thiamine - vitamin B1 and high protein diet

Question 15

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

Answer 15

corticosteroids

Question 16

how long is alcohol abstenince require for a liver transplant

Answer 16

6 months

Question 17

what is alcohol dependence

Answer 17

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.

Question 18

what is the CAGE questionaire

Answer 18

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?

Question 19

what is the AUDIT questionnaire

Answer 19

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

Question 20

what score on the AUDIT indicates harmful use

Answer 20

score of 8 or more

Question 21

what are the alcohol withdrawal symptoms at different time periods

Answer 21

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

Question 22

what is delirium tremens

Answer 22

a medical emergency associated with alcohol withdrawal

Question 23

how does alcohol work in the brain

Answer 23

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

Question 24

what does chronic alcohol use result in in the brain

Answer 24

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

Question 25

what happens when alcohol is removed

Answer 25

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

Question 26

how does delirium tremens present

Answer 26

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

Question 27

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

Answer 27

the CIWA-Ar tool

Question 28

what is used to combat the effects of alcohol withdrawal

Answer 28

Chlordiazepoxide (Librium

Question 29

what is used to prevent Wernicke-Korsakoff syndrome

Answer 29

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

Question 30

what is Wernicke Korsakoff syndrome

Answer 30

alcohol excess leads to thiamine (vit b1) deficiency.

this leads to Wernicke’s encephalopathy and Korsakoff syndrome.

Question 31

what are the features of Wernicke’s encephalopathy include:

Answer 31

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

Question 32

Features of Korsakoff syndrome include:

Answer 32

Memory impairment (retrograde and anterograde)
Behavioural changes

Question 33

what are the mortality features of both of these

Answer 33

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.

Question 34

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

Answer 34

paracetamol overdose

Question 35

when to symptoms and signs of paracetamol overdose occur

Answer 35

not until 24 hours after ingestion

Question 36

what are the signs and symptoms of paracetamol overdose

Answer 36

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

Question 37

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

Answer 37

Paracetamol level and ALT are the most important tests

Question 38

what is the paracetamol test

Answer 38

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

Question 39

what are the LFT’s in paracetamol overdose

Answer 39

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

Question 40

what is the graph used to estimate the need for treatment

Answer 40

normogram

Question 41

when should the nomogram only be used

Answer 41

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

Question 42

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

Answer 42

patients with levels more than double the nomogram line

Question 43

what is the management if <8 hours after ingestion

Answer 43

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

Question 44

what is N-acetylcystine usually administered with

Answer 44

5% dextrose

Question 45

what is the management if >8 hours after ingestion

Answer 45

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

Question 46

when should liver transplant be considered in paracetamol overdose

Answer 46

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

Question 47

what is autoimmune hepatitis

Answer 47

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

Question 48

what are the two types of autoimmune hepatitis

Answer 48

type 1 and type 2

Question 49

what is type 1 autoimmune hepatitis

Answer 49

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

Question 50

what is type 2 autoimmune hepatitis

Answer 50

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

Question 51

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

Answer 51

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.

Question 52

what are the autoantibodies found in type 1 autoimmune hepatitis

Answer 52

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

Question 53

what are the autoantibodies found in type 2 autoimmune hepatitis

Answer 53

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

Question 54

what is found in a liver biopsy in autoimmune hepatitis

Answer 54

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

Question 55

what is the management of autoimmune hepatitis

Answer 55

treatment is with high dose steroids (prednisolone)

other immunosuppresants such as azathioprine are used