You are on page 1of 22

ALCOHOLIC LIVER

DISEASE
BY MIRAEN KIANDEE
Definition
ALD has 3 stages of liver damage
Fatty liver (steatosis)
Alcoholic hepatitis (inflammation and necrosis)
Alcoholic liver cirrhosis
Epidemiology
24% of UK adults drink in hazardous or harmful way
ALD develops more rapidly and at lower dose of alcohol in women than men
About 20% of alcoholics develop fatty liver (steatosis)
If drinking continues, 40% of alcohol hepatitis develop into cirrhosis
Risk factors
Strong
Prolonged and heavy alcohol consumption
40-80g/day in men 20-40g/day in women
For 10-12 yrs
Hepatitis C
Female

Weak
Cigarette smoking
Obesity 2-3x higher
Age > 65
Hispanic ethnicity
Genetic predisposition
Diagnosis : History
Thorough history of alcohol consumption
CAGE, AUDIT, AUDIT-C questionnaires
CAGE: cut, annoyed, guilty, eye-opener
2 or more = alcohol dependence
Typical presenting symptoms
Fatigue, anorexia, weight loss, jaundice, fever, N+V, RUQ abdominal discomfort
In advanced disease
Abdo distention + wt gain = ascites
Confusion = hepatic encephalopathy
Haematemesis or malaena = GI bleed
Asterixis
Leg swelling
Diagnosis: Examination
Early stage Advanced ALD Severe hepatic involvement
- Hepatomegaly - Signs of portal hypertension: - Confusion (hepatic
- Mild jaundice Ascites encephalopathy)
- Low grade fever (in Splenomegaly - Cutaneous telangiectasia
absence of infection) Venous collateral circulations - Palmar erythema
- Finger clubbing
- Consequence of ascites: - Dupuytrens contracture
Spontaneous infection of fluid - Feminisation
Abdo hernias (gynaecomastia,hypogonadi
Difficulty breathin sm)
Decreased food intake
malnutrition
Decreased physical activity
loss muscle mass
Diagnostic tests: 1st line tests
LFTs (AST, ALT, ALP, bilirubin, protein, albumin, GGT)
FBC
Basic metabolic panel (Na, K, Cl, Bicarbonate, Urea,
Creatinine)
Mg and phosphate
Coagulation profile
Test Result
Serum AST, ALT Men > 30 units/L
Women > 19units/L

But <300 paracetamol abuse


Serum AST/ALT ratio Ratio > 2

Seen in 70% ALD


If ALT>AST = viral hepatitis/ NAFLD
Serum alkaline phosphatase Normal or

Serum bilirubin

Impaired metabolic function of liver


Serum albumin, protein Low

Impaired synthetic function of liver


Serum gamma-GT
Sensitive for heavy alcohol use and liver injury
Test Result
FBC - Anaemia ?iron deficiency, GI bleed, folate
deficiency, hypersplenism
- Leucocytosis hepatitis leukaemeoid
reaction/associated infection
- Thrombocytopenia alcohol induced bone
marrow suppression, hypersplenism, folate
deficiency
- MCV indicates alcohol abuse in absence of
B12/ folic acid deficiency
Test Result
U+E - Normal or elevated

- Elevated urea + normal Cr = active GI bleed


- Elevated urea and Cr = hepatorenal syndrome
- Hypo Na+ = common in cirrhosis
- Hypo K+ and Hypo Phos = muscle weakneses
- Hypo Mg2+ = persistent hypo K+, predisposed
to seizures
PT/INR - - synthetic function of liver
Subsequent lab test to rule out:
Viral hepatitis serological panel (Hep A, B, C)
Iron studies haemochromatosis
Copper studies Wilsons disease
Ammonia level
Folate
Anti-mitochondrial antibody PBC
Anti-nuclear antibody (ANA) + anti-smooth muscle antibody (ASMA)
AIH
Alpha-1 antitrypsin
Imaging
USS abdomen
Exclude alternative diagnosis e.g. cholecystitis, biliary obstruction, portal or
hepatic thrombosis, liver mass
Every 6-12 months for HCC screening in ALD with liver cirrhosis

CT MRI
Common findings: irregular liver margins and intrahepatic hypervascularity
Fibroscan
Ultrasonographic elastography
Assess severity of fibrosis
Liver biopsy
When to order?
+ve alcohol excess hx diagnostic + useful for grading
Atypical presentation
? Co-existing liver disease

What will it show?


Fatty infiltration in absence of inflammation = steatosis
Inflammation with necrosis + Mallory boddies = alcoholic hepatitis
Severe fibrosis (usually micronodular) starting from central vein extending into
portal triad = cirrhosis
Treatment

! Re-feeding syndrome
- close surveillance for severe
hypoK+, hypoP043-, hypoMg2+
Treatment
Treatment
Follow Up
Monitoring
Periodic liver function test
Check compliance with treatment + alcohol abstinence
Screening for oesophageal varices
> 5mm prophylactic non-selective beta-blockers e.g.
propranolol, nadolol, carvedilol +/- prophylactic
oesophageal banding
<5mm surveillance at 1-2 years interval
Follow Up
Instruction for patient
Avoid or limit alcohol
Vaccines e.g. Hep A, B, influenza, pneumococcal
- Take more protein and calories
- Limit salt intake to avoid retention
- Seek care if fever, abdo pain, SOB, palpitaitons, dizzy, coffee
ground vomit or blood in stool
Complications
1. Hepatic encephalopathy
2. Portal hypertension
3. GI bleeding
4. Coagulopathy
5. Renal failure
6. Hepatorenal syndrome
7. Hepatocellular carcinoma
8. Sepsis
Hepatic Encephalopathy
Build up of harmful toxins in blood ammonia + imbalance of amino acids
affecting brain function
Early symptoms
Forgetfulness, difficulty concentrating, rapid changes in mental state
agitation/ confusion
Asterixis / tremor
Late symptoms
stupor then coma
Treatment
Lactulose
Treatment:
1st line: beta blocker + banding
2nd line: Shunting/ TIPPS
3rd line: liver transplantation
Hepatorenal syndrome
Kidneys significantly reduce their own blood flow distribution in response to altered
blood flow in the liver
There is decreased mean arterial pressure due to vasodilation
Presents as acute kidney failure in absence of other kidney diseases
Medical Rx:
Albumin with noradrenaline
Surgical management
TIPS

You might also like