Alcoholic liver disease

Question 1

What is alcoholic liver disease?

Hint; what 3 conditions does it entail?

Answer 1

Alcoholic liver disease is a term that encompasses the liver manifestations of alcohol overconsumption, including;

fatty liver,
alcoholic hepatitis
chronic hepatitis with liver fibrosis or cirrhosis.

Question 2

What is the aetiology and risk factorsof ALD?

Answer 2

chronic, heavy alcohol ingestion

a constant high alcohol intake for 10-20 years - estimated not absolute

hepatitis C, smokers, obese = higher risk

some genetic predispostion

Hispanic people

females are at higher risk as capacity for alcohol is less!

Question 3

What are the presenting symptoms

Answer 3

1. Right upper abdominal discomfort
   - can include epigastric

others;
weight loss/gain
cachexia
fatigue
malnutrition
Fever - low - alcoholic hepatitis no infection
Pruritis - bile salt accumulation - jaundice
Peripheral neuropathy - toxic effect of alcohol

Question 4

What are the signs

Answer 4

Major;
1. Hepatomegaly;
May be present in patients with alcoholic fatty liver (steatosis) or alcoholic hepatitis

Less common;

1. Jaundice
2. Splenomegaly
3. haematemesis, malaena - gastric irritation
4. Telangiectasis;
   - there are man forms of this, can include spider naevi,
   - infact 3+ spider naevi points to Liver disease
5. Palmar erythema
6. Asterixis
7. dupytrens
8. clubbing fingers
9. gynaecomastia
10. Ascites
11. Parotid enlargement

Question 5

Identify appropriate investigations for ALD

Answer 5

Bloods - LFTs
AST, ALT, AKP, Bilirubin - in short they are all high!

1. AST and ALT are considered to be 30 units/L for men and 19 units/L for women.
   - so the results will exceed this hugely with upper limit of 300.
2. AST/ALT ratio
   The classic ratio of AST/ALT >2 is seen in about 70% of cases
3. ALP
   - normal or elevated
   - If elevated may represent cholestasis associated with ALD.
4. Bilirubin
   Both conjugated and unconjugated bilirubin are increased in varying proportion.
5. GGT
   - High. more sensitive than ast but less specific for ALD.

FBC
anaemia, high WCC, thrombocytopenia, high MCV

PT/INR
normal or elevated

Hepatic ultrasound - hepatomegaly, fatty liver etc

more specific tests for the cause;
liver biopsy, hepatitis serology etc

Question 6

Generate a management plan for alcoholic liver disease

Answer 6

1st line;
Alcohol abstinence + withdrawal management
- Oxezapam. or lorazepam.
Weight loss, smoking stop
Nutritional supplements and multivitamins*
Immunisation
- hep A, B, influenza, pneumococcal

*tend to be thiamine, folic acid, riboflavin (vitamin B2), niacin (vitamin B3), and pyridoxine (vitamin B6) deficient, so given multiviatamins. enteral feeding preferred first over other ways.

2nd line;
Liver transplant
- must be able to demonstrate rehabilitation and sustained abstinence.

Question 7

What is the meaning of a high bilirubin in lft?

Answer 7

impaired METABOLIC function of liver

in the absence of biliary obstruction

Question 8

What is the meaning of a low serum albumin?

Answer 8

impaired SYNTHETIC function of liver