6. 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.
7.
8. 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
9. 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, jaundi
ce, weight loss, ascites, signs of CLD
10.
11. History and Examination – Alcohol
Bloods including FBC, U&Es
LFTs, coagulation, cholesterol, glucose, liver
screen
Liver imaging – Ultrasound, CT/MRI
12. 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
13. 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
14. PBC
◦ IgM + Antimitochondrial antibodies
Autoimmune Hepatitis
◦ Anti ds-DNA, SMA, IgG and IgA
Sclerosing cholangitis
◦ ANCA
15. AST 4-50 77 27 1218 104
ALT 4-50 71 18 1055 114
ALK P 30-120 85 98 191 390
Bili <32 21 49 140 87
Albumin 36-46 41 43 31 39
16.
17. Differntial of large transaminitis
◦ Ischaemic Injury
◦ Acute Viral Hepatitis
◦ Paracetamol overdose
19. 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
20. Engorged veins due to portal hypertension
Develop in areas with collateral circulation
Treatment: treat
hypovolaemia, endoscopy, banding
21. Neuropsychiatric abnormalities in those with
liver disease and no attributable brain disease
Neurotoxic substances bypass liver
metabolism (eg ammonia)
22. Child Pugh score – assesses the prognosis of
chronic liver disease
23. One year Two year
Points Class
survival survival
5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%
24. Functions of the liver
Alcohol metabolism
ALD
Signs and symptoms
Liver Function tests
Complications
Prognosis
Notas del editor
Ethanol – acetaldehyde mostly catalysed by alcohol dehydrogenase with some input from the microsomal enzyme oxidising system (MEOS).Acetaldehyde – acetate catalysed by aldehyde dehydrogenase in liver mitochondriaAcetate then travels to peripheral tissues where it is activated to acetyl CoAWide variation between people as to how fast alcohol metabolism occurs – genetics, enzymesSmall amounts are eliminated unchanged in breath, sweat and urine – alcohol breath test In presence of high blood alcohol levels, drug metabolism (eg morphine) is slowed as they compete for the same cytochrome P450 enzymes
Liver damage caused by alcohol misuse. Covers a range of conditions and associated symptoms.
Scotland's rates of ALD are increasing much faster than those of the rest of the UK. This is while deaths from other chronic disease are falling.Enough alcohol is sold in Scotland each year for each adult to exceed the recommended weekly limits.Those who drink alcohol out with meal times are more than twice as likely to develop ALD.Alcohol worsens the effects of hereditary haemochromatosis in liver damage.Those in the highest deprivation category are 16 times as likely to die of CLD as those in the most affluent areas.
Steatosis – can also be seen in obesity and diabetes. Occurs in almost all heavy drinkers. Increased fatty acids are found in the liver, for which there are a number of causes. Decreased fatty acid oxidation in the mitochondria, increased transport of free fatty acids to the liver and increased production of fatty acids in the liver. Fatty change mainly occurs around central veins, where collagen is sometimes laid down too (perivenular fibrosis). If a patient stops drinking alcohol to excess, fatty liver may be reversed. Hepatitis – Liver cells damaged by excess alcohol and fatty change causing inflammation, infiltration of neutrophils, mallory bodies (proteinous substance found in cytoplasms in hepatitis, especially alcoholic) and hepatocyte necrosis. Reversible unless seen on top of a cirrhotic liverCirrhosis – 10 -20% of alcoholics progress to cirrhosis.. Characterised by inflammation, fibrosis, hepatocyte necrosis, Micronodular regeneration of the liver but with impaired architecture and function. Cirrhotic patients may have flares of hepatitis. Cirrhosis is ususally irreversible. May progress to hepatocellular carcinoma.
NAFLD – similar to ALD except patient doesnt have an alcohol historyHep B±D, C – chronic inflammation causes liver damage leading to cirrhosis. Hep D accelerates the rate of progression of Hep B to cirrhosisPSC/PBC – autoimmune diseases that can cause cirrhosis. PSC affects larger bile ducts, blocking bile and causes scarring of ducts intra and post hepatic. PBC is destruction of the small bile ducts in the liver, causing cholestatsis and liver damage. AI hepatitis – autoimmune destruction of the liver architecture leading to fibrosis and cirrhosis. Haemochromatosis – iron overloadWilson’s – copper overload
Signs of CLD including but not exclusively alcoholic liver disease. Spider naevi – central raised arteriole surrounded by smaller vessels. Due to high blood estrogen as liver cannot detoxify it. Palmar erythema – redness of thenar and hypothenar eminences due to high estrogenGynaecomastia – estrogen Finger clubbing Dupytrens contracture Ascites, caput medusaeHepatosplenomegalyJaundice, pruritis – increased bilirubin as not processed by liver AsterixisEasy bruising/bleeding – decreased production of clotting factors
Seen in all causes of cirrhosis, not just alcoholic.
Complex mechanism not completely understood.Ascites is an excess of total body water and sodium, but the cause of this is up for debate.The most recent hypothesis is that of peripheral arterial vasodilation. It says that portal hypertension, caused by a mechanical blockage of sinusoids (small hepatic vessels), decreasing radius of vessel and therefore increasing pressure, leads to vasodilation. Nitric oxide may be the vasodilator responsible. The vasodilation leads to a fall in the effective blood volume, causing the RAAS to retain sodium and water. Portal hypertension causes a locally increased hydrostatic pressure and therefore an increased hepatic and intestinal production of lymph which leaks (transudes) into the peritoneal cavity. The retention of sodium and water in turn increases the portal pressure further and forces more lymph out into the peritoneum. Hypoalbuminaemia aggravates as it reduces oncotic pressure, favouring the leakage of fluid from the sinusoids.
Areas: oesophageal, gastric, rectal, abdominal wall (caput medusae) Backflow of blood into areas of lower pressure
Bypass due to collateral circulation and the reduced function of the liver in metabolismAmmonia normally metabolised to urea in liver to become water soluble and is excreted in urineAmmonia and inflammation may cause morphologic changes to astrocytes, components of the BBB and cerebral oedema(seen in HE) HE can present with general confusion, disorientation or poor co-ordination. There is a chronic disorder of personality, mood and intellect. Asterixis (flapping tremor). Hypereflexia and increased tone.Management: identify and remove cause eg electrolyte imbalance or cerebral depressing drugs. Lactulose to empty bowels of nitrogenous substances. Treat any infection. Rifaximin to sterilise bowels long term. Protein should only be decreased in the short term.
Which parameters would be used to assess prognosis?