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Alcohol, liver disease, drugs Flashcards

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1
Q

Cells in the liver

A

Hepatocytes - 70-80% of mass
Space of DIsse:
Stellate cells 0 store vit A
Kupffer cells - macophages metbaolise dead RBC + debris

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2
Q

Blood supply to liver

A

Hepatic artery 10%
Portal vein 90%
Dual
Leaves via hepatic vein -> IVC

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3
Q

What can cause steatosis/ fatty liver disease?

A

Alcoholic liver disease
NAFLD - metabolic syndrome
eg obesity, type 2 diabetes mellitus, hypertension, hypercholesterolemia

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4
Q

Causes of NAFLD

A

Drugs-corticosteroids, oestrogen, amoxicillin, Nifedipine, Diltiazem
Viral hepatitis-hepatitis C virus
Nutritional disorders-total parenteral nutrition (TPN), postsurgical ( gastric bypass, jejunoileal bypass, small bowel resections)
Systemic disorders-inflammatory bowel disease, febrile illnesses, heatstroke
Non-insulin related metabolic disorders-Wilson’s disease, Galactosemia, tyrosinaemia
Other-Small bowel diverticulosis with bacterial overgrowth

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5
Q

What happens in steatohepatitis?

A

Histologically ballooned hepatocytes- essential finding-indicative of microtubular disruption
*may contain Mallory-Denk bodies (cytoskeletal aggregates. p62 immunohistochemistry
*Necroinflammation-Lobular inflammation-lymphocytes, macrophages and neutrophils
*Hepatic fibrosis-characteristic early fibrosis that is perivenular/pericellular

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6
Q

Definition of cirrhosis

A

Bridging fibrous septa – portal- portal
Parenchymal nodule formation
Disruption of the architecture of the entire liver – diffuse changes involving the whole liver

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7
Q

Stages cirrhosis development

A

Fatty liver disease
Liver fibrosis - scar tissue forms
Cirrhosis - scar tissue liver hard and unable to function

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8
Q

Causes of cirrhosis in developed countries

A

Top 3:
Alocholic liver disease
NAFLD
Chronic viral hepatitis hep B or C
Other causes:
Haemochromatosis
Autoimmune hepatitis
Primary and secondary biliary cirrhosis
Primary sclerosing cholangitis
Medications (eg, methotrexate, isoniazid)
Wilson disease
Alpha-1 antitrypsin deficiency
Celiac disease
Idiopathic adulthood ductopenia
Granulomatous liver disease
Idiopathic portal fibrosis
Polycystic liver disease
Infection (eg, brucellosis, syphilis, echinococcosis)
Right-sided heart failure
Hereditary hemorrhagic telangiectasia
Veno-occlusive disease

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9
Q

Signs of cirrhosis

A

Portal hypertnesion
Synthetic dysfunction
Hepatorenal syndrome
Hepatopulmonary syndrome
Encephalopathy
Hepatocellular carcinoma

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10
Q

Signs of portal hypertension

A

Ascites
Hypersplenism
Oesophageal varices

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11
Q

Synthetic dysfuntion of the liver signs

A

Coagulopathy
Hypoalbuminaemia

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12
Q

How is acute liver failure defined?

A

development of severe acute liver injury with encephalopathy and impaired synthetic function (INR of ≥1.5) in a patient without cirrhosis or preexisting liver disease

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13
Q

What can cause acute liver failure?

A

fulminant hepatic failure, acute hepatic necrosis, fulminant hepatic necrosis, and fulminant hepatitis

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14
Q

How long does liver failure have to occur for to be chronic?

A

<26 weeks

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15
Q

Cardinal symptoms of liver disease

A

Jaundice
Encephalopathy
Oedema
Abdo paun
Ascites
Pruritis
Dark urine, pale faeces
N+V, decreased appetitie
Bruises easily
Chronic fatigue

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16
Q

Functions of liver

A

Glucose storage
IMmune factors and filters bacteria
Drug and nutrient metabolism
Clears nitrogenous waste
Iron storage
Produces bile
Protein production and clotting factors

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17
Q

What alvumin lvel indicates chronic liver disease?

A

<30g/L

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18
Q

% of men and women who exceed recommended units a week?

A

31% men
16% women

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19
Q

How does SE status affect alcohol?

A

Intake is the same
Lower SE more likely to experience physical and psychological impact as a consequence of drinking

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20
Q

Harmful physical effects of alcohol

A

Acute poisonning
Most comon cause of chronic hepatitis - abdo pain and steatorrhea
Aspiration pneumonia
Mallory Weiss syndrome
Oesophagitis
Gastritis
Pancreatitis
Malabsorption and refeeding
HPTN
Cardiomyopthaty
Strokes
Seizures and DTs
Liver damage
Brain damage
Peripheral neuropathy
Myopathy
Osteoporosis
Skin disorders
Malignancies
Sexual dysfunction
Infertility
Foetal damage
Withdrawal syndrome

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21
Q

Psychological effects of alcohol

A

INsomina
Depression
Suicide/attempted
Anxiety states
Personality change
Psychotic illness
Alcoholic hallucinosis
Morbid jealousy
Amnesia
Delerium tremensn

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22
Q

What is 1 unit of alcohol uk?

A

8g
(ml x alcohol %) / 1000

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23
Q

What is a harmful levle of drinking?

A

> 50U for men
35 for women

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24
Q

How is hazardous drinking defined?

A

Pattern of alcohol increases someones risk of hamr
Physical/mental health, social consequences
Between 14 and 35 0r 50 units /week

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25
What is harmful drinking?
Level or pattern drinking causing damage to persons physical or mental heath Includes dependece syndrome Acute or chronic
26
What is low risk drinking?
<14 units over 3 or more days
27
What are the features of dependent drinking?
Strong desire or compulsion to drink Difficulties in controlling drinking Physiological withdrawal syndrome Evidence of tolerance Neglect of other pursuiits because of time spent drinking or recovering from drinking Persisting with drinking behaviour despite clear evidence of harm 3+ features over previous year
28
Physiological withdrawal syndrome
(tremor, sweating, anxiety, N+V, agitation, insomnia)
29
How to detect problem drinkers
Ask routinely at GP
30
FAST screening tool
How often do you have more than 8 units men 6 units women or more on one occasion? How often in last year have you not been able to remember what happened when drinking the night before? Hoe often in last year have you failed to do what was expected of you because of drinking? In the last year has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? 0-4 for each one 4 = daily 0 = never
31
What score indicates harmful or hazardous drinking in fast?
>3
32
What is GGT? What does elevated levels mean?
Enzyme in liver Damage to liver -> leaks into blood eg liver disease or bile duct damage
33
What use to assess alcohol level in A+E?
Blood alcohol level
34
What is acute intoxication?
Transient condition after intake psychoactive substance -> conscioussness, cognition, perception, affect or behaviour
35
What is dependence?
>2 of: Control (powerlessness) (onset, intensity, duration, termination, frequency, context) Precedence (BPS model) Physiological (tolerance, withdrawal use to prevent/alleviate) For >12 months (or 3 months if continious)
36
Physical exam and investigations in alcogol dependence
Examination Face Hands and Body CNS CVS Abdomen Genitourinary Investigations Blood tests US liver Liver biopsy
36
Physical exam and investigations in alcogol dependence
Examination Face Hands and Body CNS CVS Abdomen Genitourinary Investigations Blood tests US liver Liver biopsy
36
Physical exam and investigations in alcogol dependence
Examination Face Hands and Body CNS CVS Abdomen Genitourinary Investigations Blood tests US liver Liver biopsy
37
What would bloods of alcoholic look like?
GGT increased Macrocytic anaemia Deranged LFTs
38
Treatment of alcohol dependence
Alcohol Detoxification Pharmacotherapy Manage physical illness occurring as consequence of alcohol (e.g. Liver Transplant) Psychotherapy Social Interventions Residential Rehabilitation
39
What drug use in alcoholism when dont require detoxification?
Nalmefene
40
How long can you give Acamprosate for?
up to 6 months Stop if drinking persists after 4-6 weeks
41
How long can you give Acamprosate for?
up to 6 months Stop if drinking persists after 4-6 weeks
42
What does acamprosate do?
Prevents cravings
43
What is naltrexone and how does it work?
Opioid receptor antagonist Blockage of mu opioid receptors - reduces reinforcing effects of alcohol creased feeling intoxication and fewer cravings
44
How long naltrexone used for?
6 months or longer if needed Stop 4-6 weeks if still drinking
45
When initiate disulfiram?
24 hours after last acloholic drink
46
What need to do before prescribe disulfiram?
LFTs and U+Es Cl in severe heart disease, stroke, hypertension
47
Supervision when taking disulfiram?
Supervision every 2 weeks for first 2 months, thne monthly for 4 months
48
Interactions of disulfiram
Alcohol - food, perfume, aerosols -> Flushing, nausea, palpitations, arrhytmias, hypotnesion, collapse
49
What is a rare complication of disulfiram that is v dangerous?
Rapid and unpredicatble of rare complication of hepatoxicity jaundice or feel unwell - send help
50
Psychotherapies for alcoholism
Brief interventions MI/MET CBT Behaviorual therapy interventions eg cue exposire Relapse prevention 12 step approach smart recovery
51
What to do in motivational intervieiwng?
Helping people recognise problems or potential problems associated with their drinking Helping to resolve ambivalence and encourage positive change Adopting a persuasive and supportive rather than argumentative and confrontational position
52
When consider inpatient assistanve with alcohol withdrawal?
>30 untis/day >30 on SADQ Hisotry of epilepsy/withdrawal seizures/DT
53
When put on commnity based programme with alcohol withdrawal?
>15 units per day and/or score more than 20 on audit Limited social support Complex physical or psychiatric co-mobordities Not responded to initial community based interventions
54
What drugs class is trazadone?
SNRI
55
What happens on a community based programme?
Intensity depends on severity Drug regimen (chlordiazepoxide/oxazepam) + psychosocial support
56
When offer acamprosate or naltrexone?
If psychological therapies alonge has failed or drug treatment is preferred Alongside individual therapy
57
What can offer for mild dependence in withdrawal?
Offer psychological therapies (CBT) focussed on alcohol related cognitions, behaviour, problems and social networks or behavioural couples therapy Offer acamprosate or naltrexone
58
Moderate to severe dependence support following withdrawal
Consider acamprosate or naltrexone with psychological therapy Consider disulfiram with therapy
59
When do you consider disulfiram with psychological therapy in moderate to severe alcohol dependence?
Have goal abstinence, acamprosate or naltrexone arent suitbale Prefer disulfiram
60
Balance and movement signs of wernickes encephalopathy
Tremors Unsteady gait Wide stance and short steps Limb weakness
61
What is the triad for wernickes encephalopathy?
Confusion Ataxia Nystagmus
62
Symptoms/signs of wernickes encephalopathy
Balance and movement Confusion Nystagmus Drowsiness Postural hypotension Tachycardia
63
Thiaminereplacement treatment
IM/IV Pabrinex 5 days PO Thiamine min 4 weeks
64
What is korsakoff syndrome also related to ecept alcohol?
AIDS, infections, cancers, poor nutrtion, post bariatric surgery
65
Symptoms of korsakoff syndrome
Loss of short term memory Anterograde Hallucinations Receptive aphasia Confabulation
66
Substances that are often misused
Opiates Benzodiazepines Stimulants Cannabis Dissociative anaesthetics Hallucinogens Novel psychoactive substances Other prescription medications eg pregabalin Solvents etc
67
Which substances can cause psychosis?
Alcoholic hallucinosis Cannabis – good evidence Steroids Stimulants Cocaine Hallucinogens
68
What happens in opioid intoxication?
Dysfunctional behaviour as evidenced at least one of: Apathy and sedation Disinhibition Psychomotor retardation Impaired attention Impaired judgement Interference with personal functioning AND at least one fo the following signs: Drowsiness Slurred speech Pupillary constriction (except in anoxia from severe overdose when dilatation occurs) Decreased level of consciousness (stupor or coma)
69
Reason for presentation with drugs
In crisis Impending court case/in prison/ referred from courts Referred from/recommended by other medical practitioner/SW etc Wanting information on effects of drug use Recent health risk or anxieties re drug misuse Behaviour causing concern to others Suffering mental illness Pregnant “had enough”/ usual source not available Wanting help with drug misuse and motivated to change
70
Drugs hisotry
Age of initiation Past & current drug use Types and quantities Frequency & routes of administration Symptoms of withdrawal/ other signs of dependence Periods of abstinence / relapse Accidental overdose Funding/risky behaviours Impact
71
How to assess injecting hisotry/blood borne virus risk?
Current IV use Past IV use Use of clean equipment Supply of needles Sharing Injecting techniques Disposal of needles Knowledge of infectious diseases Practice of safe sex
71
How to assess injecting hisotry/blood borne virus risk?
Current IV use Past IV use Use of clean equipment Supply of needles Sharing Injecting techniques Disposal of needles Knowledge of infectious diseases Practice of safe sex
72
Investgiations for drug use patients
Urine drug screen blood tests if indicated Pregnancy test Infectious diseases - counselling + informed consent Collateral history from GP/family/friends
73
Building recovery from addiction
Advice /information Harm reduction Self help e.g. AA, NA, SMART recovery groups Prescribing ( if appropriate ) Goal directed counselling and psychological support Structured day programmes Detox Rehabilitation Aftercare
74
Strategies of harm reduction
Education on risks of infection/OD/safe sex/cleaning equipment Needle exchange/condom provision Hepatitis B immunisation Blood Borne Virus testing Substitute oral drugs
75
Aim of harm reduction measures
Stop drug use If using- reduce use/stop injecting If injecting - reduce/stop sharing of injecting equipment/avoid contaminated equipment If sharing - clean equipment
76
What are subsitiute treatments for opiates?
Methadone Buprenorphine injectables - diamorphine, methadone
77
Assessment for methadone
establish dependence motivation for change
77
Assessment for methadone
establish dependence motivation for change
78
What to do when commencing methaodne?
titrate against withdrawal symptoms observe hourly/ daily appointments build up over 3 days mixture used - not tablets in specialist treatment centres (drug services)
79
Functions of perscription
Retention in treatment Reduce the risks associated with injecting Reduce / prevent withdrawal symptoms Stabilise lifestyle Maintain contact with vulnerable groups Reduce criminal activity
80
How to ensure concordance/safety?
aily pick up Supervised consumption 3 -6 months Regular and spot urine testing Security (diversion/ home storage)
81
Options for detoxification of opioids
Methadone Buprenorphine Antieemetics Antidepressants, hypnotics etc Considering - severity of dependence, stability of the user, support, network/environemnt and co-morbidities
82
How long should opioid detoc be?
4 weeks inpatient No longer than 12 weeks communtiy
83
What is accelerated detox/rapid detox?
Shortened duration of detox using high dose opioid antagonists 1-5 dyas with supportive and sedative measures Use naltrexone to prevent realpse Not routinely offered
84
Relapse prevention what consisits of
Mainly Psychological Supportive Psychotherapy Self help Peer support Goal directed counselling Structured day programme Residential Rehab Treatment of any Mental Illness
85
Stimulant dependence treatment
Mainly Psychological Treatment (CBT) ?Benzodiazepines- short course Antidepressants X Anti-craving agents X Dopamine agonists Dexamphetamine (substitution in amphetamine dependence).

Mental Health (57 decks)

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