Alcoholic liver Disease (alcoholic hepatitis)

Question 1

3 stages to alcoholic liver disease?

Answer 1

(1) Fatty liver - reverses in 2 weeks if stop drinking
(2) Hepatitis - potentially reversible if permanently abstain
(3) Cirrhosis - irreversible

Question 2

Recommended alcohol consumption?

Answer 2

14 units/week –> no more than 5 units in one session

Question 3

How would you calculate units?

Answer 3

(%ABV x mls) / 1000

Question 4

How would you quickly screen for harmful use?

Answer 4

CAGE:

• Cut down?
• Annoyed?
• Guilty?
• Eye-opener?

Question 5

What screening test was developed by WHO?

Answer 5

AUDIT (Alcohol use disorders identification test)

Question 6

Complications?

Answer 6

(1) Alcoholic liver disease
(2) Cirrhosis –> HCC
(3) Dependence, withdrawal
(4) Wenicke-Korsakoff Syndrome
(5) Pancreatitis
(6) Alcoholic cardiomyopathy

Question 7

Signs of liver disease?

Answer 7

(1) Jaundice - yellow eyes, skin
(2) palmar erythema
(3) ascites
(4) hepatomegaly
(5) spider naevi
(6) easy bruising
(7) gynaecomastia
(8) asterixis
(9) Caput medusae - engorged superficial epigastric veins

Question 8

Whats bloods would you take?

Answer 8

• FBC shows raised MCV
• LFTs shows
• -> elevated AST + ALT (>2:1 ratio) + gamma-GT. ALP raises later.
• -> low albumin
• -> high bilirubin if cirrhosis
• Clotting shows elevated PT
• U&Es deranged in hepatorenal syndrome

Question 9

Scans?

Answer 9

US Liver - increased echogenicity
Fibroscan - degree of cirrhosis
CT/MRI scan - ascites, HCC, hepatospenomegaly

Question 10

What investigation can be used to assess and treat oseophageal varices (if portal hypertension suspected)?

Answer 10

Endoscopy

Question 11

Investigation to confirm diagnosis of hepatitis/cirrhosis OR if they’re starting steroids?

Answer 11

Liver biopsy

Question 12

General management?

Answer 12

(1) stop drinking
(2) detox regime
(3) nutrition - high protein, thiamine
(4) prednisolone if acute/ severe (sort infection + GI bleeds first)
(5) liver transplant

Question 13

Withdrawal symptoms at 6-12 hours?

Answer 13

• sweating
• tremor
• headache
• craving & anxiety

Question 14

Withdrawal symptom at 12-24hrs?

Answer 14

Hallucinations

Question 15

Withdrawal symptom at 24-48hrs?

Answer 15

Seizures

Question 16

Withdrawal symptom at 24-72hrs?

Answer 16

Delirium tremens

Question 17

Mortality of delirium tremens?

Answer 17

35%

Question 18

Mechanism of delirium tremens?

Answer 18

Drinking alcohol stimulates GAMA receptors + inhibits glutamate/NMDA receptors –> relaxing effect on brain

Stopping drinking causes down-regulation of GABA and up-regulation of glutamate/NMDA system –> excitability of brain + excess adrenergic activity

Question 19

Symptoms of delirium tremens?

Answer 19

• Acute confusion / agitation
• Delusions / hallucinations
• tremor
• tachycardia, hypertension, hyperthermia
• ataxia
• arrhythmias

Question 20

What tool can be used to score a patient’s withdrawal symtpoms?

Answer 20

CIWA-Ar (Clinical Institute Withdrawal Assessment)

Question 21

Medication to combat withdrawal effects?

Answer 21

Chlordiazepoxide (Librium) for 5-7 days

Question 22

Other medication to consider?

Answer 22

B1 –> IV pabrinex or oral thiamine

Question 23

Why is thiamine deficient in alcoholics?

Answer 23

(1) poorly absorbed in alcohol presence

(2) poor diet - alcohol as calories

Question 24

Features of Wenicke’s encephalopathy?

Answer 24

(1) confusion
(2) oculomotor disturbance
(3) ataxia

Question 25

Features of Korsakoff’s syndrome?

Answer 25

(1) memory impairment (anterograde + retrograde)

(2) behavioural disturbance

Question 26

If pancreatitis was suspected, what additional features to liver disease might present?

Answer 26

Epigastric pain radiating to the back + significant rise in amylase

Question 27

Liver transplant indications?

Answer 27

(1) pH <7.3 despite fluid resus

(2) All 3 of: creatinine >300, PT >100s + grade 3/4 encephalopathy

Question 28

Signs of ascites?

Answer 28

Shifting dullness + fluid thrill