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Alcohol-related liver disease (Risk factors (Amount and freq, Women>Men…
Alcohol-related liver disease
Definition
Alcohol-related liver disease
Spectrum of liver disease caused
by alcohol (steatosis, hepatitis, cirrhosis)
Alcoholic steatosis
Fatty liver caused by alcohol
Alcoholic hepatitis
Acute liver inflammation and jaundice
caused by alcohol
Alcoholic cirrhosis
Fibrosis of the liver due to alcohol
Epidemiology
Hazardous drinking 25%
Alcohol dependence
10% (M), 5% (F)
ArLD rare (<1%)
Pathophysiology
Alcohol
metabolism
Main pathway
Alcohol - acetaldehyde by alcohol dehydrogenase
Acetaldehyde - acetate by aldehyde dehydrogenase
Inducible pathway
CYP2E1 induced by presence of alcohol
Catalyses formation of acetaldehyde
If abstinance, levels reduce again
Waste products
Steatosis - excess NADH made from acetaldehyde production, feeds into Krebs to make excess fatty acids and Acetyl-CoA
ROS - oxidative stress and inflammation
Lactic acidosis - pyruvate fed into lactate pathway
Acetaldehyde - carcinogen, fibrosis, inflammation
Liver disease
development
Steatohepatitis
Immune cell influx and inflammation
often asymptomatic, reversible
Cirrhosis
Fibrosis and reduced function
Asymptomatic early, symptomatic late
Not reversible (or only partially)
Steatosis
Accumulation of fatty droplets
Asymptomatic, reversible
HCC
Small proportion of cirrhosis
Presentation
Acute alcoholic hepatitis
Alcoholic steatosis (asymptomatic)
Alcoholic cirrhosis (asymptomatic
or decompensated)
Alcohol withdrawal
Risk factors
Amount and freq
Women>Men
Age
High BMI
Poor diet
FH/genetics
Clinical
presentation
Chronic steatohepatitis/cirrhosis
Asymptomatic
Acute alcoholic hepatitis
Jaundice, confusion, N+V
Decompensation
Jaundice
Abdo distension
Confusion
Diagnosis
Examination
Abdo exam
Acute: jaundice, tender abdo
Chronic: jaundice, confusion, signs
of decompensation
Investigations
Bloods
FBC, U+E, CRP, LFT, clotting,
B12/folate, glucose, lipids,
blood cultures, alcohol levels,
virology screen (HIV, HBV, HCV)
immune screen (ANA, AMA, SMA etc.)
Imaging
USS abdo (hepatitis, cirrhosis)
CT/MRI abdo
CT head (if encephalopathic)
Bedside
Obs (any fever)
ECG (any arrhythmia)
Ascitic tap
MCS, cytology etc.
Biopsy
Not needed for diagnosis
Urine
Dipstick, MCS, ACR
History
DH
Meds, allergies
FH
Liver disease, other
medical conditions
PMH
Known CLD, other medical conditions,
previous surgeries
SH
Living arrangements, social support,
smoking,, alcohol, drugs, diet
PC/HPC
Acute: jaundice, malaise, nausea
Chronic: asymptomatic, decompensation
Management
Definitive
Medical
Vitamin supplements
Indication: acute withdrawal (DT/WK prophylaxis)
E.g. Pabrinex
Benzodiazepine
Indication: withdrawal (seizure prophylaxis)
E.g. chlordiazepoxide, diazepam
Abstinance maintenance
Indication: once acute withdrawal complete
E.g. disulfram (ALDH inhibitor)
Steroids
Indication: acute alcoholic hepatitis
E.g. PO prednisolone
Surgical
Liver transplant
Indication: end stage disease
Conservative
Information, advice, support
Alcohol support services
Monitoring (obs, fluid balance, bloods)
NG tube
Initial ABCDE