Patient Presentation, Tests and Alcoholism

Question 1

What are the important risk factors?

Answer 1

o	Alcohol intake
o	Drug use
o	Travel
o	Blood transfusions
o	Tattoos
o	Unprotected sexual activity

Question 2

What is important to identify on examination?

Answer 2

o	Fever, cachexia
o	Hepatic encephalopathy / flap
o	Signs of chronic liver disease
o	Scars off surgery – cholecystectomy
o	RUQ / epigastric pain
o	Hepatomegaly
o	Splenomegaly and ascites

Question 3

What is cachexia?

Answer 3

Extreme weight loss and muscle wasting

Question 4

When should you suspect cancer in a patient?

Answer 4

• Looking cachectic
• Have lymphadenopathy
  diseased lymphnodes causing them to become enlarged and unequal in size
• Hard, craggy liver edge
• Unintentional weight loss

Question 5

What is the most common cancer in this region of the abdomen?

Answer 5

Carcinoma of the head of the pancreas

Question 6

When should you exclude carcinoma of the head of the pancreas in patients?

Answer 6

• > 40 yrs

- Have painless, obstructive jaundice

Question 7

What is liver cancer usually caused by?

Answer 7

• Metastases from other primary cancers (lung cancer)

Question 8

When would you suspect cholangiocarcinoma (cancer of the gallbladder)?

Answer 8

When you can palpate the gallbladder on examination

Question 9

What condition is primary hepatocellular cancer is more common in?

Answer 9

Cirrhosis

Question 10

How would you test for primary hepatocellular cancer?

Answer 10

• Ultrasound

- Raised Alpha-fetoprotein (AFP)

Question 11

What are liver function tests?

Answer 11

• INR / Prothrombin time

- Albumin

Question 12

What are liver enzyme tests?

Answer 12

• Transaminases (AST, ALT)
• Alkaline phosphatase
• GGT (Gamma-GT)

Question 13

What is prothrombin time / INR?

Answer 13

A laboratory measurement of how long it takes blood to form a clot. It is used to determine the effects of oral anticoagulants on the clotting system.

Question 14

What does a rise in ALT, AST&raquo_space; rise in alkaline phosphate indicate?

Answer 14

Hepatocellular damage

Question 15

What does a rise in ALT, AST &laquo_space;rise in alkaline phosphate indicate?

Answer 15

Obstructive cause

Question 16

When would you look at gamma-GT (GGT)?

Answer 16

When there is a doubt in the tissue of origin of AST

Question 17

What are transaminases?

Answer 17

Enzymes involved with amino acid metabolism in the liver.

They are released by hepatocytes when the liver becomes damaged.

Question 18

What is the clinically relevant subcellular localisation of AST?

Answer 18

• Found in cytoplasm and mitochondria

- Is abundant in muscle and hepatocytes

Question 19

What is the clinically relevant subcellular localisation of ALT?

Answer 19

• Found in cytoplasm

- Predominatly hepatic

Question 20

Where is alkaline phosphatase found?

Answer 20

• Liver - 55%; in hepatocytes next to biliary canaliculi
• Bone - 45%; in osteoblasts
• Gut - 5%
• Kidney
• Placenta

Question 21

What could a raised alkaline phosphatase indicate?

Answer 21

- Hepatobiliary disease
     Cholestasis
     Hepatocyte disease
- Bone disease
     Paget's Disease
     Osteomalacia and rickets
     Renal osteodystrophy
     Bone metastases
     Primary bone tumour 
     Recent fracture
     Growing child - especially at puberty
- Pregnancy
- Malignancy

Question 22

What are the infective causes that can make LFTs abnormal?

Answer 22

o Epstein Barr virus
o Cytomegalovirus (CMV)
o Hepatitis A, B or C

Question 23

What are the lifestyle causes that can make LFTs abnormal?

Answer 23

o Obesity
o Alcohol excess
o Diabetes mellitus

Question 24

What are the drug causes that can make LFTs abnormal?

Answer 24

o	Anti-epileptics
o	Methotrexate
o	Rifampicin 
o	Flucloxacillin
o	Paracetamol overdose

Question 25

What are the extra-heaptic (obstructive) causes that can make LFTs abnormal?

Answer 25

o Carcinoma of the pancreas | o Gallstones

Question 26

What are the autoimmune causes that can make LFTs abnormal?

Answer 26

o Autoimmune hepatitis o Primary sclerosing cholangitis o Primary biliary cholangitis

Question 27

What are the hereditary causes that can make LFTs abnormal?

Answer 27

o Wilson’s disease o Alpha-1-antitrypsin deficiency o Hereditary haemochromatosis

Question 28

What is an alcohol unit?

Answer 28

1 unit = 10ml or 8g of pure alcohol

Question 29

What are the recommendations for drinking alcohol?

Answer 29

14 units per week, best spread out over 3+ days. Pregnant women shouldn’t be drinking at all

Question 30

What patients experience alcohol withdrawals?

Answer 30

- In patients who are alcohol dependent and who have stopped or reduced their alcohol intake within hours or days of presentation. - Symptoms typically begin 6-12 hours after the patient’s last alcoholic drink

Question 31

What are delirium tremens?

Answer 31

Acute confusional state that results when someone who drinks excess alcohol daily, suddenly stops drinking

Question 32

What can happen if delirium tremens are left untreated?

Answer 32

- Seizures | - Death

Question 33

What are the key diagnostic factors of alcoholism?

Answer 33

``` • CAGE questionnaire • AUDIT Questionnaire o Score >8 gives an indication of harmful alcohol use • Anxiety • Nausea and vomiting • Autonomic dysfunction: o Tremor o Tachycardia o Sweating o Palpitations • Insomnia ```

Question 34

What is the CAGE questionnaire?

Answer 34

o C: Have you felt the need to CUT down on your drinking? o A: Have you ever felt ANNOYED by someone criticising your drinking? o G: Have you ever felt bad or GUILTY about your drinking? o E: Have you ever had an EYE-OPENER - a drink first thing in the morning to steady your nerves?

Question 35

How do you treat delirium tremens?

Answer 35

- 1st line: oral lorazepam | - Then: parenteral lorazepam or haloperidol

Question 36

What is the management of alcohol withdrawals?

Answer 36

- 1st line: Chlordiazepoxide | - Then: Diazepam

Question 37

When would you give parenteral thiamine followed by oral thiamine for alcohol withdrawals?

Answer 37

To prevent Wernicke-Korsakoff syndrome in people who are: - Malnourished - At risk of malnourishment - Have decompensated liver disease

Question 38

What are the complications of alcoholism?

Answer 38

* Alcoholic liver disease * Cirrhosis and complications of cirrhosis including hepatocellular carcinoma * Alcohol dependence and withdrawal * Wernicke-Korsakoff Syndrome (WKS) * Pancreatitis * Alcoholic cardiomyopathy

Question 39

What is Wernicke-Korsakoff Syndrome (WKS)?

Answer 39

Thiamine (vitamin B1) deficiency - Thiamine is poorly absorbed in the presence of alcohol - Alcoholics tend to have poor diets