What are the three components of alcoholic liver disease?
Alcoholic Steatosis
Alcoholic Hepatitis
Alcoholic Cirrhosis
Define Alcoholic Hepatitis:
Inflammatory Liver Injury caused by chronic heavy intake of Alcohol
Summerise the epidemiology of Alcoholic Hepatitis:
Occurs in 10-35% of heavy drinkers
Requires 15-20 years of chronic excess alcohol intake
What percentage of patients with Alcoholic Hepatitis progress to Cirrhosis?
Around 80%
What is the pathophysiology behind Alcoholic Hepatitis?
The formation of Acetaldehyde adducts with Hepatocyte macromolecules provokes an immune response that causes liver cell necrosis and inflammation
Hepatocytes are also damaged by Oxidative species also formed by the metabolism of alcohol
Fatty liver changes are also seen
How might someone with Alcoholic Hepatitis present?
Include mild and severe:
Mild:
- Nausea
- Malaise
- Epigastric-Right Hypochondrial Pain
- Low-grade fever
Severe:
- Jaundice
- GI Bleeding
- Swollen ankles
- Tender Abdomen (w/ascites)
What signs may you find on peripheral examination of a patient with Alcoholic Hepatitis?
- Malnourished
- Jaundice if severe (50%)
- Palmar Erythema
- Dupuytren’s Contracture
- Asterixis/Fetor hepaticus (if encephalopathy)
- Easy Bruising (coagulopathy)
- Facial Telangiectasia
- Parotid Enlargement
What signs may you find on central examination of someone with Alcoholic Hepatitis?
- Spider Naevi
- Gynaecomastia
- Ascites (30-60% in severe)
- Tender Hepatomegaly
- (Splenomegaly if severe)
- Testicular atrophy
List the appropriate investigations for suspected Alcoholic Hepatitis:
(Include which bloods)
Bloods - FBC, LFTs, U&Es, Clotting
Liver Ultrasound
Percutaneous/transjugular biopsy
(endoscopy to investigate bleeding)
What blood results would you expect to see in a patient with Alcoholic Hepatitis?
- FBC:
- High WCC
- Low PLT
- (macrocytic anaemia)
- LFTs:
- High AST + ALT
- High ALP + GGT
- High Bilirubin
- Low Albumin
- U&Es: Low urea + K+
- Clotting: Prolonged PT (sensitive marker of significant liver damage)
What histopathological features might you see on a Liver biopsy of Alcoholic Hepatitis?
- Centrilobular ballooning
- giant mitochondria
- Degeneration and necrosis of hepatocytes
- Steatosis
- neutrophilic inflammation
- cholestasis
- Mallory hyaline inclusions (Mallory-Denk bodies) (eosinophilic intracytoplasmic aggregates of cytokeratin intermediate filaments)
What would you address in a treatment plan for Alcoholic Hepatitis?
Alcohol abstinence + withdrawal (Thiamine, Folic acid, Pabrinex etc.)
Fluid Status: Rehydrate, manage Ascites (spiro +/- furo)
Nutrition: may require NG feeding, protein restriction (unless encephalopathy)
Steroid therapy: Pred shown to reduce short term mortality in severe cases
(Hepatorenal syndrome: Glypressin + N-acetylcysteine)
What is the treatment for Alcoholic Hepatitis?
Alcohol cessation
(Liver transplant but probs no)
List 3 possible complications of Alcoholic Hepatitis:
Acute Liver decompensation
Hepatorenal syndrome (renal failure due to advanced CLD)
Cirrhosis
What is the mortality for patients with Alcoholic Hepatitis?
First month = 10%
First year = 40%
If continued alcohol intake - progression to cirrhosis within 1-3 yrs
