How does alcohol cause damage in the liver?
- 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
How does alcohol cause steatosis?
Interruption to the lipid metabolism pathway leads to a fatty liver even if your not fat
What is steatohepatitis?
A fatty liver causing inflammation
This can lead to fibrosis and eventually cirrhosis
What are NAFLD/NASH?
Non-Alcoholic Fatty Liver Disease
Caused by obesity and related diseases e.g. diabetes and hypercholesterolaemia
How do we detect steatohepatitis and treat it?
~maybe a biopsy
Treat with weight loss, exercise and abstinence if alcohol induced
How do we gain information about alcohol & dependancy from a patient?
- Use of CAGE questions
- Fast/Audit questionnaire about alcohol intake/effects
What are hte cage questions?
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)
What are the signs/symptoms of alcohol induced liver disease?
Jaundice, muscle wasting and other signs of chronic liver disease
Mostly dont show up until advanced disease
What are the common signs of chronic liver disease?
Spider naevi palmar erythema gynaecomastia loss of axillary and pubic hair ascites encephalopathy
What are the signs of alcholic liver disease in the lab tests??
- A high AST/ALT ratio is almost always an indicator of alcohol abuse
- Raised Gamma GT
- Macrocytosis (Enlarged RBCs)
- Thrombocytopenia (low platelets)
How does hepatic encephalopathy relate to alcoholsim?
A common feature of liver failure, its not alcohol specific but very common in alocholic liver disease
How does hepatic encephalopathy occur?
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
What are common causes for ammonia levels rising in the body?
= Infection = Drugs = Constipation = GI bleed = Electrolyte Disturbance
How do constipation and GI bleeds cause a rise in ammonia?
Faeces and blood in the gut give off/ break down to ammonia which we reabsorb into the portal circulation
How do we treat hepatic encephalopathy?
Treat the cause (antibiotics, laxatives etc) Supportive: - ITU - Airway support - NG tube for meds
How do we grade hepatic encephalopathy?
1 = mild confusion
4 = coma
What is spontaneous bacterial peritonitis? (SBP)
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.
What are the symptoms of spontaneous bacterial peritonitis?
Abdominal pain Fever/Rigors Renal Impairment Signs of Sepsis e.g. malaise, nausea, vomiting etc Tachycardic
How do investigate spontaneous bacterial peritonitis?
- Fluid protein & glucose levels
- Cell count (should show raised neutrophils)
Also exclude any surgical cause for peritonitis
How do we treat SBP?
- IV antibiotics
- Ascitic Fluid Drainage
- +/- IV albumin infusion (holds fluid in vascular space so asicites doesnt refill on drainage)
What is alcoholic hepatitis and what does it cause?
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.
What does Decompensated hepatic function mean?
When liver disease reaches the point that the rest of hte liver can no longer compensate for the damaged parts and problems begin.
How do we test for decompensated hepatic function?
Low albumin (made in liver)
Raised prothrombin time/ INR. (Liver makes clotting factors)
How do we diagnose alcoholic hepatitis?
- Low albumin
- Raised INR
- Raised Bilirubin
- Raise Gamma GT & ALP
- Alcohol history
- scan for cancers
How do we treat alcoholic hepatitis?
- 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
When/what are steroids indicated for alcoholic hepatitis?
IF Glasgow alcoholic hepatitis scoe >9 or maddreys discriminant function >32.
If score is below either then steroids do more harm than good
How do we balance the nutrition of someone with alcoholic hepatitis?
Usually have to increae caloriw intake and arrange a meeting with a dietician.
Whats the prognosis for alcoholic hepatitis?
40% mortality, 90% in severe cases
Much higher if they keep drinking, also rises with decompensated liver or encephalopathy