Professional Documents
Culture Documents
Dr Kumudith Ekanayaka
26 September 2011
Outline
Alcohol Overview
Alcohol and Health
Alcohol Related Liver Disease
Pathological Changes
History & Examination
Laboratory Investigations
Cases
Management of Advanced Liver Disease
Heberden 1699
Linked Scirrhous livers with consumption of Spirituous liquors
1916
Marked reduction in Alcohol related deaths during prohibition
Mid 1900s
Liver disease as a result of nutritional deficiency
Currently
Alcohol: Directly Hepatotoxic
1835% of injury-based ED presentations Alcoholrelated, rising to between 60-70% during the weekend
(Jones 2009; Humphrey 2003)
600 -1,000 die annually from alcohol-related causes
(Berl 2009)
Alcohol-related deaths
50% Injury, 25% Cancer, 25% Chronic disease (Connor 2005)
2007-2008 New Zealand Alcohol and Drug Survey
Alcohol Metabolism
Hepatic
Hepatic Cytosol
Gastric
Mitochondria
Gender - Female
Reduced gastric ADH
Differences in fatty acid metabolism
Twice as sensitive: More severe disease at lower
doses and duration
Up-regulation of Cytokines
CD14 and IL10
Viral Hepatitis
Hepatitis C Virus
Accelerates progression
Increases the probability of cirrhosis x8-10
Decreased survival
Related to the effect of alcohol on viral replication or on host
immune response
Pathogenesis
Normal Liver
Fatty Liver
Perivenular Sclerosis
Resolves
Continued
Drinking
Resolves
Continued
Drinking
Resolves
Continued
Drinking
1-2% pa
Alcoholic Hepatitis
Cirrhosis
Hepatocellular
Carcinoma
Hepatic Artery
Bile Duct
Portal Vein
Central Vein
Hepatic Steatosis
Short term consequence
Hours within binge
Pathology
Fat droplets
Proliferation of smooth
endoplasmic reticulum
Abnormal Mitochondria
Minimal inflammation
Alcoholic Hepatitis
LFTs
Hyperbilirubinaemia
Elevated ALP, GGT
Pathology
Fibrosis
Potentially reversible
Cirrhosis
Irreversible
Pathology
Fibrosis initially - pericentral
zone, then progresses to
panlobular fibrosis
Presence of regenerative
nodules
Patient History
Examination Findings
Asterixis
Examination Findings
Dupytrons Contracture
Examination Findings
Palmar Erythema
Examination Findings
Gynaecomastia
Examination Findings
Spider Naevi
Examination Findings
Encephalopathy
Portal Hypertension
Ascites
Splenomegaly
Venous Hum
Hepatic Injury
No single sign or
constellation of signs
is 100% specific or
sensitive for ALD
Telangectasia
Palmar Erythema
Clubbing
Dupytrons Contracture
Peripheral Neuropathy
Feminisation
Gynaecomastia
Hypogonadism
Significant Liver
Disease
Ascites
Poor Nutrition
Telengectasia
Nasopharyngeal Carcinoma
Parotid Disease
Skeletal Muscle Wasting
Cardiomyopathy
Pancreatic dysfunction
Pancreatitis
Pancreatic Insufficiency
Neurotoxicity
Wernickes-Korsakoff
Cerebellar Disease
Investigations
Ultrasound Scan
Rule out other pathology
Assess for Portal Hypertension
Nutritional Assessment
Albumin, B12, Folate and Micronutrients
Carbohydrate-deficient Transferrin
Elevated - Good sensitivity & specificity
Non Specific
Uric Acid, Lactate, TG, IgA & IgG, Ferritin
Mg2+, Glucose, PO43-, K+
Case 1 - AG
43
Routine Check-up
PMHx
Overweight
T2DM
Hypercholesterolaemia
Case 1 - AG
Bloods
FBC, U&E Normal
LFTs: Bil 6, GGT 80(), ALP 140(), ALT 75()
HbA1C: 9
Other Investigations:
Case 1 - AG
Diagnosis
Fatty Liver Disease
No evidence of Advanced Liver Disease
RF: T2DM, increased EtOH intake, BMI
Management
Risk Factor Modification
Weight loss
Reduction in EtOH intake
Control T2DM
Case 2 - FL
52
Presentation: Anorexia, Lethargy
PMHx: Pancreatitis, Previous IVDU
EtOH: 30u/wk 25 years
Examination
Tattooed
Muscle wasting
Yellow Sclera
Abdominal Distension
Case 2 - FL
Bloods:
FBC: Hb 99(), MCV 99(), Plate 78(), WC 4
LFTs: Bil 124, ALP 200, GGT 250, ALT 85 ()
Other Investigations
Liver Screen
HCV Reactive, Elevated IgA, Ferritin 400()
Case 2 - FL
Diagnosis
Alcoholic Liver Disease with Cirrhosis
Childs Pugh Score: 11 - C
Management
Immediate Abstinence with Counselling
Watch for withdrawal
Management
Abstinence
Suggested By
Bloods
Platelets, Albumin, INR, Bilirubin
Clinical Examination
Liver Specific / Other Organ injury
Imaging: USS / CT
Irregular contour, PV size, Splenomegaly, Varices
Endoscopy
Varices, Portal Hypertensive Gastropathy (PHG)
Indices of prognosis
Alcoholic hepatitis
Maddrey Discriminant Function &
Glasgow Alcoholic Hepatitis score (GAHS)
Alcoholic Cirrhosis
MELD score & Child Pugh Score
Measure
Bilirubin
<34
35-50
>50
Albumin
>35
28-35
INR
<1.7
Ascites
Enceph
Score
CPS
1 year
survival
2 year
survival
<28
5-6
100
85
1.7-2.2
>2.2
7-9
81
57
Nil
Mild
Severe
10-15
45
35
Nil
Controlled
Grade 3-4
Management - Encephalopathy
Reversible impairment of neuropsychiatric
function associated with impaired hepatic function
Limited understanding of pathogenesis
Increase in NH3 concentration implicated
Treatment
Management - Ascites
80% secondary to liver cirrhosis
Complication of PHT
Spontaneous Bacterial Peritonitis
PMN >250 cells/mm3
Increased risk with higher MELD
Treatment
Fluid Restriction
Low Na+ Intake
Diuretics Spironolactone / Frusemide
Paracentesis
Antibiotic Prophylaxis
Management - Varices
Risk of bleeding
Size, Appearance and Child-Pugh class
Treatment
Non Selective - Blocker: Nadolol, Propranolol
Oesophageal Variceal Ligation
Normal
Management - Hepatoma
Worldwide cancer
5th Diagnosis, 2nd Death
7th Diagnosis 6th death
Treatment
Transplant If within criteria
Transarterial Chemoembolisation (TACE),
Radiofrequency Ablation (RFA)
Management - Transplant
Consideration
Childs Pugh C
Hepatoma
Other complications
Encephalopathy, Ascites
Co-morbid disease
Pancreatitis and cardiomyopathy