Path: Liver 4 - Disease + Cirrhosis (ii)

Presentation of alcohol-related liver damage

vague symptoms

found through screening or identified in @ risk pops

abnormal LFTs, fatty change/cirrhosis on US, abnormal transient elastography (FirbroScan)

acute episodes of alcohol hepatitis

decompensated cirrhosis

AUDIT/CAGE questionnaires

direct Qs

collat hx

hints (not specific or sensitive): raised gGT, elevated MCV

don't assume harmful/heavy drinking is the sole or even main cause - excl others

alcohol may interact with other causes of liver damage (HCV, HFE, paracetamol)

tx = abstinence

Pathological effects of alcohol abuse

alcohol-related liver disease

acute and/or chronic pancreatitis (acute from binge drinking)

gastritis, erosions, PUD, oesophageal tears from vomitting

increases risk of HTN + hypertensive (haemorrhagic) stroke

CNS disturbance (Wernicke-Korsakoff syndrome)

Wernicke's encephalopathy (thiamine deficiency) + Korsakoff psychosis

long term cerebellar or cortical atrophy

cognitive impairment

peripheral neuropathy

acute myopathy + long term muscle wasting

dilated CM

possible malnutrition, increased risk of infection (TB, lobar pneumonia)

increased risk of breast cancer

risk of trauma (head injury, fractures, RTA, suicide)

during pregnancy: foetal alcohol syndrome, poor birth outcomes (unlikely with v low dose)

NAFLD

spectrum of histological changes identical to alcohol-related liver disease

fatty change = most common manifestation by far

NASH present in a few

cirrhosis - common cause of previously cryptogenic cirrhosis (unknown origin)

abstinent or modest alcohol intake

typically a/w metabolic syndrome (v common)

a/w increased mortality, but mostly from CVD not liver disease

rate/risk of progression not clarified

host factors?

only a few progress

commonest presumptive dx in those sent for assessment to liver clinical with abnormal LFTs

assess activity/fibrosis

non-invasive methods preferable

ELF (enhanced liver fibrosis) blood test

FibroScan

avoid biopsy

weightloss

exercise

modify underlying metabolic syndrome risk factors

statins (they may increase transaminases but benefit outweighs risk)

Haemochromatosis

excessive iron deposition in tissues, causing damage

hereditary

progressive excessive absorption relative to need

specific gene defect in HFE gene (chromo 6p) in most patients (esp Ire)

rarely non-HFE gene associated hereditary haemochromatosis

secondary haemochromatosis = secondary to iron overload

caused by multiple transfusions, ineffective erythropoiesis a/w hereditary anaemias (e.g. thalassaemia - rare in Ire)

toxic iron deposition

liver (fibrosis + cirrhosis)

endocrine pancreas (secondary DM)

myocardium (dilated CM)

ant pituitary (secondary hypogonadism + impotence)

arthropathy

fatigue (most common symptom but not specific)

skin hyperpigmentation ("bronze diabetes") - overstim of melanocytes

symptoms rare in under 40s

men present before women (women more prone to anaemia)

biochemical iron overload

high % saturation of transferrin/total iron bind capacity (>55% = significant)

ferritin sensitive but less specific (acute phase reactant, rise can be a/w inflamm) - good to use for followup

hereditary haemochromatosis excluded if transferrin sat <45% + ferritin normal

genetic testing (HFE) if abnormal iron storage status confirmed

liver biopsy rare (occasionally for dx/staging)

Perls' stain used to highlight haemosiderin (blue deposits) - indicates massive overload

tx = venepuncture (safe + easy)

Genetics

traditionally thought to be rare, but increasing recognition

2 mutations: C282Y + H63D

most cases are homozygotes

60% of compound C282Y + H63D heterozygotes @ risk

biochem overload more common than clinical disease

variable penetrance of genetic trait (mostly in males)

screen 1st degree relatives if mutation identified