Alcoholic liver disease

Question 1

Why does alcohol damage the liver?

Answer 1

• Alcohol is directly toxic to the liver (especially with chronic exposure)
• Alcohol interrupts/affects many metabollic pathways like gluconeogenesis and lipid metabolism

Question 2

What are the pathways for ethanol metabolism?

Answer 2

Oxidative:

Ethanol –> Acetaldehyde –> Acetate

Done by Dehydrogenase enzymes

Microsomal enzyme oxidation system:

Ethanol –> Acetaldehyde

Done by Cytochrome P45…

Question 3

What is steatosis and how does alcohol cause it?

Answer 3

Steatosis means fatty liver

Fat builds up as alcohol interrupts the lipid metabolic pathway so it accumulates

Question 4

What is steatohepatitis?

What is the long term effect on the liver?

Answer 4

Fatty liver with inflammation (neutrophilic infiltration)

Inflammation causes fibrosis. The scar tissue builds up and the liver becomes cirrhotic.

Question 5

What are signs of chronic liver disease?

Answer 5

Ascites (distended abdomen)

Jaundice

Muscle wasting

Spider naevi

Gynaecomastia

Palmar erythema

Loss of axillar, pubic and chest hair

Question 6

What lab tests will show alcohlic damage to the liver?

Answer 6

Raised AST:ALT ratio (>2)*

Raised Gamma Glutamyl Transferase (GGT)

Macrocytosis (enlarged RBCs)

Thrombocytopenia (low platelets)

Aspartate aminotransferase (AST)*

Alanine transaminase (ALT)

Question 7

What imaging modality is best for showing fatty liver?

Answer 7

Ultrasound scan

Question 8

What is hepatic encephalopathy?

Answer 8

Syndrome characterised by a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction/failure, after exclusion of brain disease

It happens when there is a rise in ammonia levels in the body, but the damaged liver cannot manage it

Question 9

How is hepatic encephalopathy graded?

Answer 9

Graded 1-4:

1 - milnd confusion

4 - coma

Question 10

What are the causes of hepatic encephalopathy?

(ie causes of raised ammonia levels)

Answer 10

Infection

Drugs

Constipation

GI bleed

Electrolyte disturbance

(in someone with a shitty liver)

Question 11

Hepatic encephalopathy is diagnosed through ruling out other conditions such as neurological ones which cause the symptoms.

What causes/problems must be ruled out?

Answer 11

Infection

Hypoglycaemia

Intracranial bleed

Question 12

How is hepatic encephalopathy treated?

Answer 12

Treat cause…

Bowel clear out, Lactulose (laxative), Enemas

Antibiotics

Supportive management:

• ITU
• Airway support
• Nasogastric tube for meds

Question 13

What is lactulose?

Answer 13

A laxative

Given rectally in hepatic encephalopathy

Question 14

Symptoms for spontaneous bacterial peritonitis?

Answer 14

Abdominal pain

Fever

Rigors (shivering/feeling cold)

N&V (sepsis)

Question 15

What are the signs of spontaneous bacterial peritonitis?

Answer 15

Ascites

Sepsis - malaise, N&Vs etc

Tachycardia

Pyrexia

Signs of renal impairment

Question 16

How is spontaneous bacterial peritonitis investigated?

Answer 16

Ascitic tap procedure (peritonocentesis)

• fluid protein & glucose levels
• cultures
• cell count (SBP –> neutrophilia)

This is a type of paracentesis when ascites fluid is drained from the peritoneum. It can be used to investigate (samples) and to fully drain the fluid.

Question 17

What is done with the fluid sample taken in an ascitic tap procedure?

(give values needed for diagnosis)

Answer 17

Protein levels <25g/L

Glucose levels

Cultures - typically E.coli

White cell content - Neutrophil count >0.25x10⁹ /L

Question 18

What must be excluded to diagnose spontaneous bacterial peritonitis?

Answer 18

Surgical causes must be excluded

Question 19

How is spontaneous bacterial peritonitis be treated?

Answer 19

• IV antibiotics
• Ascitic fluid drainage (ascitic tap)
• +/- IV albumin infusion (20% ALBA) - holds fluid in the vasculature so ascites doesnt refill after drainage

Question 20

What is alcoholic hepatitis and how does it present?

Answer 20

Inflammation of the liver due to excess alcohol intake. Often associated with steatosis/steatohepatitis.

It can cause cirrhosis, presenting with:

Jaundice

Encephalopathy

Infection common

Decompensated hepatic function

Question 21

What measurements indicate decompensated hepatic function?

Answer 21

Low albumin

Raised prothrombin time (aka INR)

Question 22

What does prothrombin time actually mean?

Answer 22

Basically how long the blood takes to clot

Question 23

How is a diagnosis of Alcoholic hepatitis made?

Answer 23

• low albumin
• raised INR (prothrombin)
• raised bilirubin
• raised GGT & ALP
• history of excess alcohol
• exclusion through imaging of cancer or other causes

Question 24

What is the prognosis for alcoholic hepatitis?

Answer 24

40% mortality

In severe cases, 90% mortality

Also higher if patient:

• Continues drinking alcohol
• Presented with encephalopathy

Question 25

How is alcoholic hepatitis treated?

Answer 25

Supportive Steroids (if severe) Treat infection Treat encephalopathy Treat alcohol withdrawal Protect against GI bleeding Airway Protection / ITU care

Question 26

How severe must alcoholic hepatitis be before treatment with steroids is indicated?

Answer 26

Glasgow Alcoholic Hepatitis Score \>9 or Maddrey's discriminant function \>32

Question 27

What is Maddreys discriminant function?

Answer 27

Maddrey discriminant function (DF) is the traditional model for evaluating the severity and prognosis in alcoholic hepatitis and evaluates the efficacy of using alcoholic hepatitis steroid treatment

Question 28

What nutritional management is given to people with alcoholic hepatitis?

Answer 28

High **energy/calorie** intake High **thiamine** intake Frequent feeds +/- Consultation with dietician

Question 29

How many people in the population have a 'fatty liver'?

Answer 29

25-40%

Question 30

What are risk factors/causes of fatty liver development?

Answer 30

Obesity Diabetes Hypercholesterolaemia High alcohol intake

Question 31

Steatohepatitis (fat + inflammation) is histologically similar to what?

Answer 31

Liver damaged by alcohol

Question 32

'A 1/4 of patients with steatohepatitis will develop \_\_\_\_\_\_'

Answer 32

Liver cirrhosis

Question 33

What are the symptoms of Steatohepatitis?

Answer 33

Asymptomatic

Question 34

What signs/investigations show steatohepatitis?

Answer 34

Raised Alanine amino transferase Fatty liver on USS Liver Biopsy

Question 35

How is steatohepatitis treated?

Answer 35

Weight loss Exercise