Week 15 - Alcoholic hep, hep and drug overdose Flashcards
what is the step wise progression of alcohol-related liver disease
- alcoholic fatty liver (hepatic steatosis)
- alcoholic hepatitis
- cirrhosis
what is step 1 - alcoholic fatty liver
drinking leads to a build up of fat in the liver. this process is reversible with abstinence
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
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
what is binge drinking defined as in men and women
in women, 6 units or more and in men, 8 units or more
what are the examination findings with excess alcohol
Smelling of alcohol
Slurred speech
Bloodshot eyes
Dilated capillaries on the face (telangiectasia)
Tremor
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
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
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)
what can be used to assess for and treat oesophageal varices when portal hypertension is suspected
endoscopy
what can be used to look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites
CT and MRI
what can be used to confirm the diagnosis of alcohol related hepatitis or cirrhosis
liver biopsy
what is the one general principle to manage alcohol related disease
stop drinking alcohol permanently
what vitamins are given to people with liver disease
thiamine - vitamin B1 and high protein diet
what may be used to reduce inflammation in severe alcoholic hepatitis to improve short term outcomes
corticosteroids
how long is alcohol abstenince require for a liver transplant
6 months
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.
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?
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
what score on the AUDIT indicates harmful use
score of 8 or more
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
what is delirium tremens
a medical emergency associated with alcohol withdrawal
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
