Alcoholic liver disease

• There is a stepwise progression of alcohol-related liver disease:

  1. Alcoholic fatty liver (hepatic steatosis) - process is reversible with abstinence
  2. Alcoholic hepatitis
  3. Cirrhosis
• 80% of patients with alcohol related hepatitis progress to cirrhosis - increased risk of hepatocellular carcinoma
• Presentation of alcohol induced hepatitis:

  The clinical presentation ranges from mild to severe. A mild clinical presentation would be a patient presenting with fever, right upper quadrant pain or discomfort, and elevations in aminotransferases that normalizes with sobriety. While a severe presentation would include jaundice, ascites, hepatic encephalopathy, and coagulopathy.
• In alcohol induced liver disease the AST:ALT ratio is normally 2:1
• Treatment of alcohol induced hepatitis:

  • Screen for infection - ascitic fluid tap
  • Stop alcohol - treat withdrawal symptoms
  • Vitamin K and thiamine - IV pabrinex
  • Prednisolone - after liver biopsy
• Patients with severe alcoholic hepatitis may be considered for treatment with corticosteroids - does not improve long term outcomes
• Complications of alcohol:

  • Alcohol-related liver disease
  • Cirrhosis and its complications - hepatocellular carcinoma
  • Alcohol dependence and withdrawal
  • Wernicke-Korsakoff syndrome
  • Pancreatitis
  • Alcoholic cardiomyopathy
  • Alcoholic myopathy
  • Increased risk of cancer - breast, mouth and throat
• Blood test results suggesting alcohol related liver disease:

  • Raised MCV
  • Raised AST and ALT (usually a 2:1 ratio)
  • Raised Gamma-GT

  In late disease/cirrhosis:

  • Raised bilirubin - reduced liver synthetic function
  • Low albumin - reduced liver synthetic function
  • Increased INR/PT - reduced liver synthetic function
  • Deranged U&Es - hepatorenal syndrome
• Liver ultrasound may show early fatty changes with increased echogenicity. It can also be used to assess cirrhosis, where it will show nodularity of the liver surface.

  Patients with liver cirrhosis should receive an ultrasound scan every 6 months plus alpha-fetoprotein to screen for hepatocellular carcinoma
• Alcohol dependence involves a risk of withdrawal symptoms. Delirium tremens occur 24-72 hours after the last alcoholic drink and have a 35% mortality rate if left untreated.
• Chronic alcohol use results in the GABA system becoming down-regulated and the glutamate system becoming up-regulated to balance the effects of alcohol. When alcohol is withdrawn there is extreme excitability of the brain with excessive adrenergic activity
• Signs and symptoms of alcohol withdrawal:

  • Acute confusion
  • Severe agitation
  • Delusions and hallucinations
  • Tremor
  • Seizures
  • Tachycardia
  • Hypertension
  • Arrhythmias
  • Ataxia
• Management of patients withdrawing from alcohol is based on the CIWA-Ar tool:

  • 1st line is chlordiazepoxide (benzodiazepine)
  • Delirium tremens - first line oral lorazepam, then parenteral lorazepam or haloperidol
  • IV pabrinex followed by long term oral thiamine to prevent Wernicke's encephalopathy
• Patients with alcohol related liver disease or alcohol dependency should be given nutritional support with thiamine (vitamin B1)
• Wernicke's encephalopathy is an acute neurological condition characterised by:

  • Opthalmoparesis (impaired horizonal eye movement) with nystagmus
  • Ataxia
  • Confusion
• Wernicke's encephalopathy is causes by a thiamine deficiency (vitamin B1). Thiamine is poorly absorbed in the presence of alcohol. It is treated with immediate IV thiamine replacement.
• Wernicke's encephalopathy itself is reversible but can result on Korsakoff syndrome. Korsakoff syndrome is a permanent neuropsychiatric disorder associated with memory disturbances, delirium and unsteady gait
• The CAGE questions can be used to quickly screen for harmful alcohol use:

  • C – CUT DOWN? Do you ever think you should cut down?
  • A – ANNOYED? Do you get annoyed at others commenting on your drinking?
  • G – GUILTY? Do you ever feel guilty about drinking?
  • E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
• The UK recommendations are not regularly to drink more than 14 units per week. This should be spread evenly over 3 or more days and not more than 5 units in a single day. Binge drinking is defined as 6 or more units for women and 8 or more for men in a single session.
• Alcohol units= (volume (ml) x ABV %) / 1000

  • 1 x 25ml shot of 40% alcohol is 1 unit
  • Small glass of wine= 1.5 units
  • Pint of 4% beer = 2.2 units
• Delirium tremens is a medical emergency that requires specialist inpatient care. In patients with delirium tremens (characterised by agitation, confusion, paranoia, and visual and auditory hallucinations), oral lorazepam should be used as first-line treatment. If symptoms persist or oral medication is declined, parenteral lorazepam, or haloperidol can be given as adjunctive therapy.
• Features of hepatic decompensation:

  • Jaundice
  • Ascites
  • Coagulopathy (raised INR)
  • Hypoalbuminemia
  • Hepatic encephalopathy