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Flashcards in Alcoholic Liver Disease Deck (60)
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1

Leading cause of liver transplantation in US

Alcoholic liver disease (replaced HCV)

2

Patterns of injury in alcoholic liver disease

Fatty liver (Simple steatosis)- present in almost all with chronic alcohol abuse
Alcoholic hepatitis
Chronic hepatitis with fibrosis or cirrhosis

3

Progression of liver with ALD

Normal liver
Steatosis
Steatohepatitis
Fibrosis
Cirrhosis
Hepatocellular carcinoma

4

When is there an increased risk of developing cirrhosis?

Men >3 drinks per day > 5 yrs
Women > 2 drinks per day> 5 yrs

5

Risk factors of ALD

Women are more sensitive to alcohol (develop more severe at lower doses with shorter duration)
African American>Hispanic>Caucasian males
Obesity
Genetic factors
Hep C leads to more rapid progression of liver disease
Smoking (risk of hepatocellular cancer)

6

Recommendation for alcohol for HCV obese pt

No more than 1 drink per day

7

Risk factors for ALD based on alcohol

Amt ingested (most important)
Type maybe (beer or spirits more)
Pattern (drinking outside of meal time is worse)

8

Pathophysiology of fatty liver (hepatic steatosis)

Increased mobilization of free fatty acid from peripheral fat stores
Increased TAG formation
Decreased fatty acid oxidation
Reduced lipoprotein release by liver

9

Simple uncomplicated fatty liver

Usually asymptomatic and self limited (may be completely reversible with abstinence for 4-6 wks)

10

What is alcoholic hepatitis?

Inflammation of liver characterized by necrosis and fibrotic scarring (with history of chronic or current heavy alcoholic consumption

11

Presentation of alcoholic hepatitis

Can be asymptomatic, mild or severe
Severe with marked impairment of liver function:
Low fever, leukocytosis
Hepatic encephalopathy
Spider angiomas
Jaundice, hepatosplenomegaly with liver tenderness, edema, ascites, variceal bleeding!!!
Oliguria

12

What is hepatic encephalopathy?

When liver can't get rid of toxins like ammonia (due to hepatocellular dysfunction and portosystemic shunting) and they develop neuro sxs

13

Labs seen in alcoholic hepatitis

Leukocytosis with left shift
Macrocytosis (MCV>100)
Thrombocytopena
AST/ALT ratio 2:1 (AST is 2-6x ULN) but both <300
ALP mildy elevated
Elevated bilirubin (more direct)
PT/INR elevated
Low albumin
Hyponatremia, hypokalemia
GTP elevated
Low folate

14

What is seen on histology for alcoholic hepatitis?

Fatty infiltration
Neutrophil infiltration around clusters of necrotic hepatocytes
Clumps of intracellular material (Mallory bodies)
Fibrosis around hepatic venules (precursor to cirrhosis)

15

How to diagnose ALD

Liver biopsy required when unclear history of alcohol use and elevated liver tests and it is confounded by other risk factors for liver disease and we're considering tx with steroids

16

Tx of hepatic encephalopathy

Treat precipitating factors (GI bleeding, infection, sedating meds, lyte abnormalities, constipation and renal failure)
Lactulose for overt HE and secondary prophylaxis (also can use rifaximin)

17

Signs of hepatic encephalopathy

EEG changes and flapping tremor (asterxisis-put hands out and back and they tremor)

18

Grades of hepatic encephalopathy

I- changes in behaviors, mild confusion, slurred speech, disordered sleep (sublinical or covert encephalopath)
II- lethargy, moderate confusion (asterixsis)
III-marked confusion (Stupor), incoherent speech, sleeping but can arouse
IV-coma, unresponsive to pain

19

Stroop test

For HE
Brief cognitive screening tool to evaluate psychomotor speed and cognitive flexibility (can diagnose minimal HE well)

20

Management of alcoholic hepatitis

Hospitalize if high mortality rate (based on risk assessment calculators)
Discontinue all alcohol and complete abstinence is essential
If fluid overloaded, use diuretics (ascites etc)
Sodium restricted diet
Discontinue nonselective BBs b/c increased risk of AKI

21

Risk calculators for alcoholic hepatitis

Model of End Stage Liver Disease (MELD)> 20 is severe with poor prognosis
Maddery discriminant factor (MDF) >32 is severe AH
Lillie score (labs over time) is used to determine if steroids should be continued!!!

22

Tx for severe alcoholic hepatitis

MDF>32 or MELD>20
Consider the steroid tx and discontinue if no effective on day 7 using Lillie score
Liver transplant in select population

23

What is cirrhosis?

Widespread destruction and regeneration of liver tissue with marked increase in fibrotic connective tissue
Regenerated liver tissue forms nodules and permanently alters structure
Impaired liver function when increased connective tissue
Necrosis and fibrosis leads to deteriorration
Can have inflammatory cell infiltration

24

What is compensated cirrhosis?

Portal pressure <10
Median survival about 12 yrs
May have splenomegaly (thrombocytopenia, leukopenia, anemia, AST elevation)

25

What is decompensated cirrhosis?

Increased portal pressure with decreased liver function
Median survival <2 yrs
Hepatic BF is bypassing vascular scars
Have portal HTN, porto-systemic shunting and impaired liver function

26

Clinical manifestations of cirrhosis with increased portal HTN

Ascites
Esophageal and rectal varices
Splenomegaly
Dilated abd veins
Encephalopathy
Jaundice

27

Extra manifestations of decompensated cirrhosis

Fatigue, anorexia, weakness, palmar erythema, parotid enlargement, Dupuytrens contracture, jaundice, gynecomastia, testicular atrophy, spider nevi, muscle wasting, anemia
Signs of HE
Similar labs to alcoholic hepatitis

28

Sites of obstruction in portal HTN

Prehepatic (portal vein thrombosis)
Intrahepatic (cirrhosis)
Posthepatic (CHF, constrictive pericarditis)

29

What is the problem with portal HTN?

Promotes collateral circulation:
Esophageal varices and rectal varices that can bleed
Splenomegaly
Ascites (caput medusa)
HE

30

Labs in cirrhosis

Similar to alcoholic hepatitis
AST elevation (Can be normal in compensated)
Anemia
Thrombocytopenia
Coag abnormalities (not synthesize clotting factors)