Flashcards in Gastroenterology Deck (300)
Outline the spectrum of alcohol-related liver disease?
- Alcoholic fatty liver disease- Alcoholic hepatitis - Cirrhosis
How can alcohol-related liver disease progress?
- Can be a stepwise progression; fatty liver --> alcoholic hepatitis --> cirrhosis - In reality progression can be highly variable - Influenced by genetic predisposition
What is alcoholic fatty liver?
- Excess ingestion of alcohol and its subsequent metabolism leads to the deposition of excess fat in the liver- May occur with or without concurrent inflammation- Reversible in around 2 weeks following cessation of drinking
What is alcoholic hepatits?
- Acute onset of symptomatic hepatitis due to severe inflammation of the liver - Associated with sustained excess alcohol ingestion or acutely due to binge drinking - Mild forms are reversible with permanent abstinence of drinking
What is alcohol-related liver cirrhosis?
- Irreversible scaring of the liver - Associated with numerous complications- Abstinence can prevent further damage- Continued drinking has very poor prognosis
What is the rough threshold alcohol consumption that is said to significantly increases the risk of developing alcoholic hepatitis?
- Consumption >100g per day for 15-20 years - Approximately 12.5 units per day
What is the relationship between alcohol units and ABV?
"- 1L of 5% ABV = 5 units- 1L of 40% ABV = 40 units
Units = ABV / (1000/Volume )"
Outline the DoH guidance for alcohol consumption in the UK?
- No more that 14 units per week spread evenly over 3 or more days- No more than 5 units in any single day - Alcohol should be completely avoided in pregnancy
What questions can be used to screen for harmful alcohol use?
"CAGE Questions;- Cutting down; has patient considered cutting down - Annoyed; does patient get annoyed about others commenting on their drinking - Guilt; has patient ever felt guilty about drinking- Eye opener; does pateint ever drink in the morning to help with hangovers/nerves"
What questionnaire can be used to screen patients for harmful alcohol use?
AUDIT Questionnaire;- Alcohol use disorders identification test- Score > 8 indicates harmful use
Outline some of the complications of alcohol?
- Alcoholic liver disease- Cirrhosis and the complications of which can include hepatocellular carcinoma- Alcohol dependance and withdrawal- Wernicke-Korsakoff Syndrome (WKS); vitamin B1 (thiamine) deficiency - Pancreatitis- Alcoholic Cardiomyopathy
Which scoring system can be used to assess the severity of alcoholic hepatitis?
Maddrey Discriminant Function (DF)- Based on prothrombin time and serum bilirubin- DF > 32; severe hepatitis - DF < 32; mild-to-moderate hepatitis
What scoring system can be used to assess mortality amoung patients with alcoholic hepatitis?
Glascow Alcoholic Hepatitis Score (GAH);- Score > 9; severe alcoholic hepatitis, 46% 28-day survival
What signs can often be seen upon examination of a patient with alcoholic liver disease?
- Jaundice- Hepatomegaly - Spider naevi - Palmar erythema - Dupuytren's contracture- Bruising; due to abnormal clotting- Ascites- Caput medusae; engorged superficial epigastric veins due to portal hypertension- Asterixis; flapping tremor in decompensated liver disease
What blood tests should be carried out in a patient with suspected alcoholic liver disease?
- FBCs; raised MSV in alcholics, likely elevated neutrophil count- LFTs; derranged - Clotting; elevated prothrombin time- U&Es; may be derranged in hepatorenal syndrome
What imaging can be used to investigate potential alcoholic liver disease?
- Liver ultrasound with dopplers can be used to assess the achitecture of the liver, may show fatty changes described as increased echogenicity - FibroScan; can be used to assess the elasticity of the liver to assess the degree of cirrhosis
What is meant by a non-invasive liver screen?
"- Series of non-invasive investigations to determine the possible causes of liver disease - Includes screening questions, imaging and blood tests
Outline some of the changes that may be seen in the LFT blood test results for a patient with alcoholic liver disease?
- Elevated ALT and AST; AST/ALT ratio > 2 (secondary to pyridoxal-5-phosphate deficiency) - Particularly raised γ-GT- ALP can also be raised in late-stage disease- Low albumin due to reduced synthetic function of the liver- Elevated bilirubin in cirrhosis
Why may the INR or prothrombin time be elevated in patients with alcoholic liver disease?
- Reduced synthetic function of the liver- Impaired synthesis of coagulation factors - Hence increased time to coagulate
What investigation can be carried out in severe cases of alcoholic liver disease or in patients who are being considered for steroid therapy?
- Liver biopsy; assess for underlying cirrhosis, steatosis, neutrophil infiltration, hepatocytes ballooning, Mallory-Denk bodies
What are Mallory-Denk bodies?
"- Eosinophilic accumulations of proteins within the cytoplasms of hepatocytes that may be seen in liver biopsies- Whilst they have no pathological role in disease they are a marker of alcohol-induced liver disease
Outline the key management principles for alcoholic liver disease?
- Managing alcohol withdrawal; CIWA Scoring, benzodiazepines, alcohol team input- Alcohol cessation - Hydration; fliud resuscitation, HAS in patients with ascites- Nutrition; high dose thiamine (Pabrinex)- Treatment of complications; infection, portal hypertension and oesophageal varices - Pharmacolgical therapy; corticosteriods (prednisolone, 40mg OD, 28-days)
Outline some of the effects of alcohol withdrawal?
- 6-12hrs; tremor, sweating, headache, cravings, anxiety- 12-24hrs; hallucinations- 24-48hrs; seizures- 24-72hrs; delerium tremens
What is delerium tremens?
- Medical emergency associated with alcohol withdrawal- Potential fatal complication if left untreated (35% mortality)
- Signs o Acute confusion o Severe agitation o Delusions and hallucinations o Tremor o Tachycardia o Hypertension o Hyperthermia o Ataxia
o Acute confusion
o Severe agitation
o Delusions and hallucinations
What causes delerium tremens?
- Alcohol stimulates GABAnergic neurones and inhbits NMDA glutamatergic neurones - Chronic alcohol used results in an up-regulation of the GABA system and a downregulation of the glutamate system to balance these effects- When alcohol is removed the GABA system underfunctions and the glutamate system overfunctions - This leads to extreme excitability in the brain leading to excess adrenergic stimulation
What scoring system can be used to assess the severity of alcohol withdrawal symptoms and guide treatment?
CIWA-Ar Tool;- Scores > 9 require medication for withdrawal
Outline some of the pharmacological managment options for patients experiencing alcohol withdrawal?
- Chlordiazepoxide (Librium); oral benzodiazepine, reducing regime (10-40mg every 1-4hrs) for 5-7 days - Thiamine suppliments; intitially IV high dose (Pabrinex) followed by regular dose oral thiamine
What is Wernicke-Korsakoff Syndrome (WKS)?
- Combination of Wernicke's encephalopathy and Korsakoff's syndrome - Caused by thiamine deficiency
What is Wernicke's encephalopathy?
- Medical emergency with a high mortality rate- Confusion- Oculomotor disturbances- Ataxia - Due to vitamin B1 (thiamine) deficiency
What is Korsakoff's syndrome?
- Irreversible complication seen in alcoholic liver disease - Results in patient requiring full-time institutional care
- Memory impairement; both retrograde and anterograde- Behavioural changes
- Memory impairement; both retrograde and anterograde