ALD, NASH, NAFLD

Question 1

Name the common genetic link between fatty liver disease and both ALD and NAFLD/NASH.

Answer 1

PNPLA3

Question 2

Describe the histology of alcoholic liver disease.

Answer 2

any combination of: fatty liver, hepatitis, and cirrhosis

macrostaosis
hepatocelluar ballooning
lobular inflammation
perisinusoidal fibrosis

Question 3

Name the criteria for metabolic syndrome.

Answer 3

impaired glucose tolerance
abdominal obesity
hypertriglyceridemia
low levels of HDL
high blood pressure
(obstructive sleep apnea
PCOS)

Question 4

How is NAFLD different from AFLD?

Answer 4

> 5% macrosteatosis in the absence of ETOH use

mallory bodies not expected with non-alcoholic etiologies

Question 5

____ ___ ___ is the 2nd most common indication for liver transplantation, second only to hepatitis.

Answer 5

alcoholic liver disease

Question 6

Describe how the gut microbiome has a key role in ALD and NAFLD.

Answer 6

chronic ethanol can lead to “leaky gut” mucosa which increases translocation of bacterial products, induction of cytokines and oxidative stress

** important interaction of TLR4 activation of cupful cells that leads to cytokines like TNFa and release of ROS

cytokines also cause activation of stellate cells which can begin to produce collagen (fibosis)

Question 7

Describe the prescribed way to screen for alcohol abuse.

Answer 7

Do you ever think you need to cut-down
Angry/Annoyed at how much people complain about your drinking
feel guilty about your drinking
need an eye opener when you first wake up

DUI and rehab visits can be useful follow ups

Question 8

How common is it for patients to able to achieve abstinence?

Answer 8

59% relapsing subjects did so after 6mo abstinance

41% who achieved 2yrs abstinence, relapsed subsequently

abstinence was secure only after 5 years

Question 9

Name factors that lead to relapse.

Answer 9

social isolation- lack of employment, no fixed abode, living alone or no spouse/companion
lack of insight into addiction
hx. of many failed rehab attempts
psychiatric co-morbid conditions, including uncontrolled polysubstance abuse or unstable character disorder)

Question 10

What pharmacotherapies are recommended for alcohol use cessation?

Answer 10

disulfiram (potentially toxic in cirrhosis)
naltrexone (black box warning)
acamprosate: not studied in cirrhosis
topiramate (anticonvulsant): not studied in cirrhosis
baclofen (efficacy in 1 RCT of cirrhosis)

Question 11

How do you manage NAFLD/NASH?

Answer 11

weight loss is key (bariatric surgery can be helpful), improves steatosis but not liver fibrosis
vitamin E improves some aspect of liver histology