Alcoholic Liver Disease

Functions of the liver Alcohol metabolism ALD Signs and symptoms Liver Function tests Complications Prognosis

Storage – glycogen, vitamins, iron, copper

Metabolism – Drugs (incl alcohol), carbohydrate, lipid, protein

Production – Bile, albumin, clotting factors, hormones

Functions of the liver

Acetate then oxidised in peripheral tissues via citric acid cycle to CO2, fatty acids and water, producing energy

Alcohol metabolism

Three stages:

Alcoholic fatty liver (Steatosis)

Alcoholic hepatitis

Cirrhosis

ALD

Over 90% of chronic heavy drinkers will develop steatosis

10-20% will develop alcoholic hepatitis ALD cause of death of 1 in 50 people in

Scotland. 4 fold increase in deaths from ALD in past

30 years. Risks: alcohol quantity/pattern, gender (F),

Hep C infection, haemochromatosis, genetic factors, malnutrition, deprivation.

Epidemiology/Risks

Not just end result of alcoholism

Non alcoholic fatty liver disease (NAFLD) Chronic Hepatitis B ± D or C PSC/PBC AI hepatitis Haemochromatosis Wilson’s disease

Cirrhosis - causes

Steatosis: usually asymptomatic, hepatomegaly

Alcoholic hepatitis: malaise, jaundice, tender hepatomegaly, fever, weight loss, abdominal discomfort

Cirrhosis: Similar to other causes of cirrhosis. Hepatomegaly, splenomegaly, malaise, jaundice, weight loss, ascites, signs of CLD

Signs and symptoms

Chronic liver Disease

History and Examination – Alcohol

Bloods including FBC, U&Es LFTs, coagulation, cholesterol, glucose, liver screen

Liver imaging – Ultrasound, CT/MRI

Assessment

LFTS Synthetic function

◦ Albumin, INR Hepatic enzymes

◦ AST, ALT Cholestatic enzymes

◦ Alk Phos, Gamma GT Inducible enzymes

◦ Gamma GT Bilirubin

◦ if isolated consider Gilberts or Haemolysis

LFTS Hepatitis

◦ Increased ALT/AST, mild GGT mild Alk phos◦ Serology

Alcohol◦ Increased ALT/AST, large GGT, moderate Alk phos◦ Ethanol and MCV◦ High AST:ALT (2:1)

Gallstones/primary Biliary cirrhosis◦ Large Alk Phos, Large GGT, mild ALT/AST

Autoantibodies + Ig PBC

◦ IgM + Antimitochondrial antibodies Autoimmune Hepatitis

◦ Anti ds-DNA, SMA, IgG and IgA Sclerosing cholangitis

◦ ANCA

AST 4-50 ALT 4-50 ALK P 30-120 Bili <32 Albumin 36-46

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Differntial of large transaminitis◦ Ischaemic Injury◦ Acute Viral Hepatitis◦ Paracetamol overdose

Ascites

Portal hypertensive bleeding

Hepatic encephalopathy

Complications of cirrhosis

Peritoneal fluid accumulation – transudate Portal hypertension - ↑ pressure on portal

vein Sodium and water retention due to

vasodilatation (RAAS) Hypoalbuminaemia due to ↓ synthetic

function of liver – low plasma oncotic pressure

Ascites

Engorged veins due to portal hypertension Develop in areas with collateral circulation Treatment: treat hypovolaemia, endoscopy,

banding

Variceal bleeding

Neuropsychiatric abnormalities in those with liver disease and no attributable brain disease

Neurotoxic substances bypass liver metabolism (eg ammonia)

Hepatic encephalopathy

Child Pugh score – assesses the prognosis of chronic liver disease

Prognosis

Points Class One year survival

Two year survival

5-6 A 100% 85%7-9 B 81% 57%10-15 C 45% 35%

Functions of the liver Alcohol metabolism ALD Signs and symptoms Liver Function tests Complications Prognosis

Summary