An introduction to alcoholic liver disease part 2
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This document provides an overview of alcoholic liver disease (ALD) in multiple parts. It begins by discussing how alcohol is metabolized in the liver and can cause liver dysfunction by damaging hepatocytes and producing toxic byproducts. The major manifestations of ALD are then described, including jaundice, coagulopathy, and encephalopathy, which result from impaired bilirubin metabolism, clotting factor synthesis, and other liver functions. The document outlines the spectrum of ALD from fatty liver to alcoholic hepatitis to cirrhosis. Diagnosis involves assessing alcohol use history and liver enzymes/function. The characteristics of fatty liver, alcoholic hepatitis, and cirrhosis are summarized.
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An introduction to alcoholic liver disease part 2
- 1. Alcoholic Liver disease: an introduction part 2 Pratap Sagar Tiwari, Lecturer, NGMC
- 2. Our Journey Alcohol & Liver Clinical Features Making a diagnosis Complications Portal Hypertension Hepatic encephalopathy Management
- 3. Alcoholic liver disease liver dysfunction because of Alcohol Liver Dysfunction What then ? Because of Alcohol How ?
- 4. Functions that are affected.. • Detoxification • Bilirubin metabolism • Clotting factors Synthesis of • Thrombopoietin • Albumin • Angiotensinogen CHO /protein/ lipid metabolism Storage of Vitamins
- 5. Manifestations… Jaundice • Bilirubin metabolism • Clotting factors • Detoxification Coagulopathy Encephalopathy
- 6. Definition • Any pathological conditions of liver as a result of chronic and excessive alcohol consumption leading to a spectrum of conditions from ranging from asymptomatic fatty liver to alcoholic hepatitis to end-stage liver failure with jaundice, coagulopathy, and encephalopathy.
- 7. Metabolism of Alcohol Ethanol Citric Acid cycle Oxidized Acetaldehyde alcohol dehydrogenase IB (ADH) CYP2E1 Catalase Tetrahydroisoquinolines CO2/ATP (TIQs) Acetaldehyde dehydrogenase enters Acetyl-coenzyme A synthetase acetyl-CoA Acetic acid Note: Disulfiram inhibits Acetaldehyde dehydrogenase
- 8. Alcohol & Acetaldehyde If not metabolized,releases free radicals Damage to embryonic neural crest cells = birth defects Alcohol forms “Adducts” that activate immune system cell injury Cytochrome CYP2E1 metabolizes ethanol to Acetate, releasing oxygen free radical radical induced injury Alcohol ↑ gut permeability ↑ endotoxin Kupffer cells activation TNF a, IL6 Inflamation Alcoholic liver Disease Free Radicals:eg superoxide ( O2- ),hydrogen peroxide (H2O2), peroxynitrite Antioxidants are Vit A,C,E, Superoxide dismutase, beta carotene, glutathione
- 9. • Beginning of Part 2………
- 10. ALD: Spectrum • The pathology of alcoholic liver disease consists of three major lesions, with the injury rarely existing in a pure form: (1) fatty liver, (2) alcoholic hepatitis, (3) cirrhosis.
- 11. Diagnosis of alcoholic liver disease 1. A thorough history of alcohol use. 2. CAGE:screening method for alcohol abuse or dependency. 3. A detailed P/E should be done, searching for signs of CLD and staging its severity. 4. A liver chemistry profile (including serum albumin, bilirubin and transaminases [AST/ALT]). CBC & PT/INR. 5. It may be necessary to perform a liver biopsy in patients with suspected alcoholic liver disease when the diagnosis is unclear .
- 12. CAGE Questionaaire • Have you felt the need to Cut down drinking? • Have you ever felt Annoyed by criticism of drinking? • Have you had Guilty feelings about drinking? • Do you ever take a morning Eye opener ?
- 13. ALD:Fatty liver • Fatty liver, also known as fatty liver disease (FLD), is a reversible condition wherein large vacuoles of triglyceride fat accumulate in liver cells via the process of steatosis (i.e., abnormal retention of lipids within a cell). • AFL(steatosis) is rarely diagnosed clinically because most patients are asymptomatic. • The only complaint may be mild, tender hepatomegaly. • DX: in pt with alcohol abuse/dependent with fatty changes in imaging and excluding other causes. LFT may be normal/mild abnormal.
- 14. Microvesicular fat Macrovesicular fat Alcoholic foamy degeneration Acute fatty liver of pregnancy Reye's syndrome Valproic acid Tetracycline Alcohol Malnutrition Obesity Diabetes mellitus Corticosteroids Total parenteral nutrition
- 15. ALD: Alcoholic hepatitis • The characteristic clinical features of alcoholic hepatitis are fever, hepatomegaly, jaundice, and anorexia. • Patients can also present with right upper quadrant/epigastric pain, hepatic encephalopathy, and bleeding.
- 16. ALCOHOLIC CIRRHOSIS AND FIBROSIS • The term "fibrosis" in this setting denotes the accumulation of scar or extracellular matrix (ECM), and is potentially reversible in the absence of continued alcohol abuse. • In contrast, true cirrhosis is characterized by the presence of regenerative nodules and is irreversible even in the absence of further alcohol ingestion.
- 17. Acute liver failure • Acute liver failure is an uncommon condition in which the rapid deterioration of liver function results in coagulopathy and alteration in the mental status (encephalopathy) of a previously healthy individual.
- 18. Liver failure: definitions • Acute liver failure is a broad term that encompasses both fulminant hepatic failure and subfulminant hepatic failure (or late-onset hepatic failure). • Fulminant hepatic failure is generally used to describe the development of encephalopathy within 8 weeks of the onset of symptoms in a patient with a previously healthy liver. • Subfulminant hepatic failure is reserved for patients with liver disease for up to 26 weeks before the development of hepatic encephalopathy.
- 19. Next Part : • Clinical features………….
- 20. • End of Part two………….
Notas del editor
- ethanol is oxidized to acetaldehyde mainly via the hepatic enzyme alcohol dehydrogenase IB (class I), beta polypeptide (ADH1B).Alcohol dehydrogenase: The name "alcohol dehydrogenase" sounds like quite a mouthful, but it is quite self-explanatory if we break it down into its component parts. "de-" is a prefix which means "to remove". We find it in such words as "dethrone" which means "to remove from the throne". "-ase" is a suffix which means "enzyme". Any time you see a chemical term which ends in the suffix "-ase" you know that you are dealing with an enzyme. "hydrogen" means "hydrogen" of course. So "de-hydrogen-ase" means "an enzyme which removes hydrogen atoms", and "alcohol dehydrogenase" means "an enzyme which removes hydrogen atoms from the alcohol molecule". The name alcohol dehydrogenase is sometimes abbreviated to ADH.The acetaldehyde released into the brain by the metabolism of alcohol by catalase has the potential to combine with neurotransmitters to form new compounds known as THIQs (tetrahydroisoquinolines, also sometimes called TIQs). Some researchers believe that THIQs are the cause of alcohol addiction and that the presence of THIQs distinguishes addicted drinkers from social drinkers.Acetaldehyde is a highly unstable compound and quickly forms free radical structures which are highly toxic if not quenched by antioxidants such as ascorbic acid (Vitamin C) and Vitamin B1 (thiamine). These free radicals can result in damage to embryonic neural crest cells and can lead to severe birth defects. Prolonged exposure of the kidney and liver to these compounds in chronic alcoholics can lead to severe damage.Acetaldehyde dehydrogenase does its work in the mitochondria of cells and removes a hydrogen atom from acetaldehyde to produce an acetic acid radical. This hydrogen atom combines with NAD+ to form NADH. This excess of NADH can lead to acidosis from lactic acid build-up and hypoglycemia from lack of glucose synthesis.The [NAD+]/[NADH] ratio in the cytosol of cells is a major regulatory mechanism. As the [NADH] increases, the ratio decreases.The citric acid cycle itself was finally identified in 1937 by Hans Adolf Krebs while at the University of Sheffield, for which he received the Nobel Prize for Physiology or Medicine in 1953
- A thorough history of alcohol use should be obtained. The CAGE questionnaire is a useful screening method for alcohol abuse or dependency.A detailed physical examination should be done, searching for signs of chronic liver disease and staging its severity.A liver chemistry profile (including serum albumin, bilirubin and transaminases [AST/ALT]). A complete blood count and prothrombin time or INR should be obtained.It may be necessary to perform a liver biopsy in patients with suspected alcoholic liver disease when the diagnosis is unclear because of atypical features or possible concomitant disease.