Alcoholic Liver Disease

Question 1

How does alcohol cause damage in the liver?

Answer 1

• Alcohol is directly toxic to the liver. Mostly it causes liver failure over chronic exposure, but some people can have acute liver failure due to alcohol
• It also interrupts a lot of metabolic processes such as gluconeogenesis or lipid metabolism

Question 2

How does alcohol cause steatosis?

Answer 2

Interruption to the lipid metabolism pathway leads to a fatty liver even if your not fat

Question 3

What is steatohepatitis?

Answer 3

A fatty liver causing inflammation

This can lead to fibrosis and eventually cirrhosis

Question 4

What are NAFLD/NASH?

Answer 4

Non-Alcoholic Fatty Liver Disease
Non-Alcoholic Steatohepatitis

Caused by obesity and related diseases e.g. diabetes and hypercholesterolaemia

Question 5

How do we detect steatohepatitis and treat it?

Answer 5

Ultrasound
~maybe a biopsy
Raised ALT

Treat with weight loss, exercise and abstinence if alcohol induced

Question 6

How do we gain information about alcohol & dependancy from a patient?

Answer 6

• History
• Use of CAGE questions
• Fast/Audit questionnaire about alcohol intake/effects

Question 7

What are hte cage questions?

Answer 7

Just a few questions that help determine someones dependance on alcohol:

• ever felt the need to Cut down
• Annoyed by criticism of your drinking?
• Guilty about your drinking?
• need an Eyeopener? (morning drink)

Question 8

What are the signs/symptoms of alcohol induced liver disease?

Answer 8

Jaundice, muscle wasting and other signs of chronic liver disease
Mostly dont show up until advanced disease

Question 9

What are the common signs of chronic liver disease?

Answer 9

Spider naevi
palmar erythema
gynaecomastia
loss of axillary and pubic hair
ascites
encephalopathy

Question 10

What are the signs of alcholic liver disease in the lab tests??

Answer 10

• A high AST/ALT ratio is almost always an indicator of alcohol abuse
• Raised Gamma GT
• Macrocytosis (Enlarged RBCs)
• Thrombocytopenia (low platelets)

Question 11

Macrocytosis?

Answer 11

Enlarged RBCs

Question 12

How does hepatic encephalopathy relate to alcoholsim?

Answer 12

A common feature of liver failure, its not alcohol specific but very common in alocholic liver disease

Question 13

How does hepatic encephalopathy occur?

Answer 13

Confusion due to ammonia in the brain
Normally the liver breaks down ammonia to urea.
Something happens to cause a rise in ammonia and the damaged liver fails to keep up causing acute hepatic encephalopathy

Question 14

What are common causes for ammonia levels rising in the body?

Answer 14

= Infection
= Drugs
= Constipation
= GI bleed
= Electrolyte Disturbance

Question 15

How do constipation and GI bleeds cause a rise in ammonia?

Answer 15

Faeces and blood in the gut give off/ break down to ammonia which we reabsorb into the portal circulation

Question 16

How do we treat hepatic encephalopathy?

Answer 16

Treat the cause (antibiotics, laxatives etc)
Supportive:
- ITU
- Airway support
- NG tube for meds

Question 17

How do we grade hepatic encephalopathy?

Answer 17

1-4 with:
1 = mild confusion
4 = coma

Question 18

What is spontaneous bacterial peritonitis? (SBP)

Answer 18

Infection of the peritoneum, usually with ascites.

Again not exclusive to alcohol but as a result of liver cirrhosis, its very common with chronic alcohol use.

Question 19

What are the symptoms of spontaneous bacterial peritonitis?

Answer 19

Abdominal pain
Fever/Rigors
Renal Impairment
Signs of Sepsis e.g. malaise, nausea, vomiting etc
Tachycardic

Question 20

How do investigate spontaneous bacterial peritonitis?

Answer 20

Ascitic tap:

• Fluid protein & glucose levels
• Cultures
• Cell count (should show raised neutrophils)

Also exclude any surgical cause for peritonitis

Question 21

How do we treat SBP?

Answer 21

• IV antibiotics
• Ascitic Fluid Drainage
• +/- IV albumin infusion (holds fluid in vascular space so asicites doesnt refill on drainage)

Question 22

What is alcoholic hepatitis and what does it cause?

Answer 22

Inflammation of the liver due to excess alcohol (usually chronically), often associated with steatosis/steatohepatitis.

IT can cause cirrhosis leading to -> jaundice, encephalopathy, decompensated hepatic function.

Question 23

What does Decompensated hepatic function mean?

Answer 23

When liver disease reaches the point that the rest of hte liver can no longer compensate for the damaged parts and problems begin.

Question 24

How do we test for decompensated hepatic function?

Answer 24

Low albumin (made in liver)

Raised prothrombin time/ INR. (Liver makes clotting factors)

Question 25

How do we diagnose alcoholic hepatitis?

Answer 25

• Low albumin
• Raised INR
• Raised Bilirubin
• Raise Gamma GT & ALP
• Alcohol history
• scan for cancers

Question 26

How do we treat alcoholic hepatitis?

Answer 26

• Treat complications e.g. infection (SBP) & Encephalopathy
• Stop alcohol & treat withdrawel
• Steroids (if indicated)
• Balance nutrition
• Airway protection/ITU care
• Supportive Care
• Protection against GI bleeds

Question 27

When/what are steroids indicated for alcoholic hepatitis?

Answer 27

IF Glasgow alcoholic hepatitis scoe >9 or maddreys discriminant function >32.

If score is below either then steroids do more harm than good

Oral Prednisalone

Question 28

How do we balance the nutrition of someone with alcoholic hepatitis?

Answer 28

Usually have to increae caloriw intake and arrange a meeting with a dietician.

Question 29

Whats the prognosis for alcoholic hepatitis?

Answer 29

40% mortality, 90% in severe cases

Much higher if they keep drinking, also rises with decompensated liver or encephalopathy