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Year 3 Gastro > Alcoholic Liver Disease > Flashcards

Alcoholic Liver Disease Flashcards

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1
Q

What quantity of alcohol is sufficient to cause alcoholic liver disease?

A

40 to 80 g/day in men and 20 to 40 g/day in women for 10 to 12 years

in absence of co-morbidities

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2
Q

What is the first line treatment for alcoholic liver disease?

A

Alcohol abstinence

Enzyme tests to monitor ongoing liver damage

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3
Q

What are some complications of ALD?

A 
Oesophageal or gastric variceal bleeding
Ascites
Coagulopathy
Hepatic encephalopathy
Liver cancer
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4
Q

What are the three defining stages of ALD?

A

fatty liver (steatosis)

alcoholic hepatitis (inflammation and necrosis)

alcoholic liver cirrhosis

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5
Q

What are risk factors for ALD?

A

Prolonged heavy alcohol consumption
Presence of hepatitis C
Female sex

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6
Q

What are common diagnostic factors for ALD?

A

Risk factors
Right upper abdominal discomfort
Hepatomegaly

Ascites
Weight loss/gain
Malnutrition and wasting
Anorexia
Fatigue
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7
Q

What are some less common diagnostic factors for ALD?

A

Haematemesis and melaena

Venous collaterals - caput medusae, engorged para-umbilical veins

Splenomegaly

Hepatic mass

Jaundice

Palmar erythema - thenar and hypothenar eminences, sparing central portions

Cutaneous telangiectasia

Asterixis

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8
Q

When is jaundice common?

A

Common in severe alcoholic hepatitis and in decompensated severe alcoholic cirrhosis

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9
Q

When is jaundice uncommon?

A

Uncommon in compensated alcoholic cirrhosis or alcoholic steatosis

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10
Q

What are cutaneous telangiectasia?

A

Vascular spiders with central arteriole flanked by smaller vessels. Usually seen on the trunk, face, and upper limbs.

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11
Q

What is asterixis?

A

Flapping motions of outstretched, dorsiflexed hands; quick test for encephalopathic state.

Manifestation of hepatic encephalopathy present in advanced ALD

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12
Q

How can ascites be evaluated?

A

Shifting dullness

Fluid wave examination

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13
Q

Why might patients with ALD loose weight?

A

High tumour necrosis factor (TNF)-alpha and inflammatory response

Leads to loss of appetite

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14
Q

Why might patients with ALD gain weight?

A

Ascites or oedema

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15
Q

What are some weaker risk factors for ALD?

A 
Cigarette smoking
Obesity
Age > 65
Hispanic ethnicity
Genetic predispostion
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16
Q

What are the 1st investigations to order is ALD?

A 
Serum AST and ALT
AST/ALT ratio
Alkaline phosphatase
Bilirubin
Albumin/protein
Gamma glutamyl transferase
FBC
Electrolytes, Mg, phosphorus
Urea and Cr
PT and INR
Hepatic ultrasound
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17
Q

What are AST and ALT?

A

AST - aspartate aminotransferase

ALT - alanine aminotransferase

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18
Q

What are the upper limit of normal values for ALT and AST?

A

30 units/L for men and 19 units/L for women

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19
Q

What happens to the ALT/AST ratio in ALD?

A

AST elevated more than ALT

AST/ALT > 2 seen in 70% of cases

Ratio reversal where ALT>AST suggests viral hepatitis or non-alcoholic fatty liver disease

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20
Q

What would raised alkaline phosphatase suggest in ALD?

A

Cholestasis associated with ALD

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21
Q

What would happen to serum albumin in ALD?

A

Low

Impaired synthetic function of the liver

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22
Q

What would happen to gamma-GT in ALD?

A

Increase representing enzyme activation induced via alcohol

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23
Q

What could be seen on a FBC in ALD?

Study These Flashcards
A

Anaemia
Leukocytosis
Thrombocytopenia
High MCV

24
Q

What could cause anaemia in ALD?

Study These Flashcards
A 
Iron deficiency
GI bleeding
Folate deficiency
Haemolysis 
Hypersplenism
25
What could be wrong with electrolytes in ALD?
Hyponatraemia Hypokalaemia Hypophosphataemia Hypomagnesaemia
26
What does elevated INR/PT suggest in ALD pts?
Liver cirrhosis or liver failure
27
When should hepatic ultrasound be conducted in liver patients?
Pts with harmful alcohol abuse Screen for hepatocellular carcinoma (every 6-12 months) for those with ALD
28
What abnormalities may be seen on an abnormal hepatic ultrasound?
``` Hepatomegaly Fatty liver Liver cirrhosis Liver mass Splenomegaly Ascites Evidence of portal hypertension ```
29
What investigations should be considered in ALD?
Viral hepatitis serology Serum iron, ferritin, transferrin Urine copper (24 hour) > 40mg = potentialWilsonn's diseaaes e eeum ceruloplasmin Serum a
30
What are the histopathological features of alcoholic hepatitis?
``` Centrilobular ballooning Degeneration and necrosis of hepatocytes Steatosis - fatty change Neutrophilic inflammation Cholestasis Giant mitochondria ```
31
Summarise the epidemiology of alcoholic hepatitis
Occurs in 10-35% of heavy drinkers
32
Recognise the presenting symptoms of alcoholic hepatitis
May remain asymptomatic and undetected May be mild illness with symptoms such as: ``` o Nausea o Malaise o Epigastric pain o Right hypochondrial pain o Low-grade fever ``` More severe presenting symptoms include: o Jaundice o Abdominal discomfort or swelling o Swollen ankles o GI bleeding
33
What are some signs of alcoholic hepatitis on PE?
o Malnourished o Palmar erythema o Dupuytren's contracture o Facial telangiectasia – red lines appear due to widened venules o Parotid enlargement o Spider naevi o Gynaecomastia o Testicular atrophy o Hepatomegaly o Easy bruising
34
What are some signs of severe alcoholic hepatitis?
o Febrile (in 50% of patients) o Tachycardia o Jaundice o Bruising o Encephalopathy o Ascites o Hepatomegaly o Splenomegaly
35
Describe the features of encephalopathy in alcoholic hepatitis?
(e.g. liver flap, drowsiness, disorientation) – caused by build up of ammonia in blood (which is normally removed by the liver) – crosses blood-brain barrier
36
What is first line treatment for all patients?
Alcohol abstinence +/- withdrawal management Weight reduction + smoking cessation Nutritional supplementation + multivitamins (thiamine - pabrinex) Immunisations If severe- corticosteriods
37
What measures can be used to aid alcohol abstinence?
``` Counselling Brief intervention Psychotherapy AA Rehab programmes ```
38
What drugs are most commonly used to treat withdrawal?
Long acting benzodiazepines - prevent seizures/delirium Diazepam 10mg IV followed by 5-10mg every 3/4 hours
39
What is the management plan for acute alcoholic hepatitis?
o Thiamine o Vitamin C and other multivitamins (can be given as Pabrinex) o Monitor and correct K+, Mg2+ and glucose o Ensure adequate urine output o Treat encephalopathy with oral lactulose or phosphate enemas – decrease ammonia generation by bacteria o Ascites - manage with diuretics (spironolactone with/without furosemide) o Therapeutic paracentesis (removing fluid) o Glypressin and N-acetylcysteine for hepatorenal syndrome
40
What is 2nd line treatment for ALD?
Transplant
41
What are the possible complications of ALD?
Acute liver decompensation Hepatorenal syndrome Cirrhosis
42
What immunisations are recommended for all ALD patients?
Flu Pneumococcal Hep A and Hep B if antibody tests are neg
43
What 3 enzymes convert alcohol to acetaldehyde in the liver?
Cytochrome p450 Alcohol DeHydrogenase Catalase
44
How do you diagnose alcoholic liver disease?
AST>ALT Raised WCC, reduced platelets Neutrophilic leucocytosis Mallory-denk body on histopathology
45
What is the treatment for encephalopathy caused by alcoholic liver disease?
Oral lactulose | Phosphate enemas
46
When might steroids be used?
To reduce short-term mortality for severe alcoholic hepatitis
47
What is Cirrhosis?
Irreversible end-stage liver damage Regenerative nodules seen on histology Band of protein around it
48
How is cirrhosis caused?
Fibrosis is mediated by stellate cells, usually dormant cells that store vitamin A Damaged hepatocytes release factors that activate cells Release vitamin A, start proliferating and produce tgf-beta TGF-beta cause collagen formation which causes fibrotic tissues Pressure compressed sinusoid and veins leading to portal hypertension
49
What causes portal hypertension?
Fibrotic tissue Pressure compressed sinusoid and veins leading to portal hypertension Fluid leaks to relieve pressure causing ascites
50
What causes cirrhosis?
Chronic alcoholic misuse - common in UK | Chronic viral hepatitis - common worldwide
51
What can precipitate decompensation?
``` Infection GI bleed Constipation Alcohol Drugs Portal vein thrombosis ```
52
What are the signs of cirrhosis?
``` Jaundice Distended abdomen Hepatic encephalopathy Splenomegaly Easy bruising Gynaecomastia Erythema ```
53
What are investigations for Cirrhosis?
FBC - reduced platelets LFTs - raised ALT/AST/Bilirubin Prolonged PT Liver biopsy - gold standard
54
What is the management for cirrhosis?
Treat the cause Treat the complications Liver transplant
55
What are the key histological features of alcohol related liver disease?
Ballooning (+/- Mallory Denk Bodies) Fat Pericellular fibrosis Mainly seen in zone 3 (around the central veins)
56
How as nomenclature changed re alc/non-alc liver disease?
MAFLD - metabolic associated fatty liver disease MASH - metabolic associated steatohepatitis some pts have alcoholic/fatty due to obesity/metabolic changes so cannot strictly classify as alc or non-alc

Year 3 Gastro (39 decks)

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