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G34 Gastroenterology
Standard Drink Equivalent
1 standard drink= 14 g EtOH = 12 oz beer (5% alcohol)
= 5 oz wine (12-17%)
= 3 oz fortified wine (17-22%) = 1.5 oz liquor (40%)
Tip: percentage alcohol multiplied by oz in 1 standard drink roughly equals 60
Biopsy + Histology of Alcoholic Hepatitis (triad)
• Hepatocyte necrosis with surrounding
inflammation in zone III
• Mallory bodies (intracellular eosinophilic
aggregates of cytokeratins)
• Chicken-wire fibrosis (network of
intralobular connective tissue surrounding cells and venules)
GI Complications of Alcohol Abuse
• Esophagus
■ Mallory-Weisstear
■ Esophagealvarices(secondarytoportal
hypertension) • Stomach
■ Alcoholicgastritis • Pancreas
■ Acutepancreatitis
■ Chronicpancreatitis • Liver
■ Alcoholichepatitis
■ Fattyliver
■ Cirrhosis
■ Hepaticencephalopathy ■ Portalhypertension
■ Ascites ■ HCC
Liver Toronto Notes 2019 Alcoholic Liver Disease
Definition
• spectrumofdiseases,rangingfrom:
■ fatty liver (common amongst individuals with alcohol use disorder): reversible if alcohol stopped ■ alcoholic hepatitis (35% of individuals with alcohol use disorder): usually reversible if alcohol
stopped
■ cirrhosis (10-15% of individuals with alcohol use disorder): potentially irreversible
Pathophysiology
• severalmechanisms,poorlyunderstood • ethanoloxidationtoacetaldehyde
■ reduces NAD+ to NADH; increased NADH decreases ATP supply to liver, impairing lipolysis so fatty acids and triglycerides accumulate in liver
■ binds to hepatocytes evoking an immune reaction
• EtOHincreasesgutpermeabilityleadingtoincreasedbacterialtranslocation • alcoholmetabolismcauses:
■ relative hypoxia in liver zone III (near central veins; poorly oxygenated) > zone I (around portal tracts, where oxygenated blood enters)
■ necrosis and hepatic vein sclerosis • histologyofalcoholichepatitis
■ ballooned (swollen) hepatocytes often containing Mallory bodies, characteristically surrounded by neutrophils
■ large fat globules
■ fibrosis: space of Disse and perivenular
Clinical Features
• >2-3standarddrinks/dinfemalesand>3-6standarddrinks/dinmenfor>10yrleadstocirrhosis,but only in about 10-20% of those who consume this amount daily on a continuous basis; cirrhosis risk increases with amount of alcohol consumed above threshold
• clinicalfindingsdonotaccuratelypredicttypeofliverinvolvement
• fattyliver
■ mildly tender hepatomegaly; jaundice rare
■ mildly increased transaminases <5x normal
• alcoholichepatitis
■ variable severity: mild to fatal liver failure
■ mild: stops drinking because feels unwell, resumes when feeling better (if assessed, findings of
hepatitis, potentially mild jaundice, and mildly elevated INR)
■ severe: stops drinking but feels unwell, low grade fever, RUQ discomfort, increased white blood cell
count – mimics RLL pneumonia and cholecystitis
Investigations
• bloodtestsarenon-specific,butingeneral ■ AST:ALT >2:1 (both usually <300)
■ CBC: increased MCV, increased WBC often seen with alcoholic hepatitis but not necessarily in
other alcohol-related liver injury
■ increased GGT
Treatment
• alcoholwithdrawal(seePsychiatry,PS24)
■ Alcoholics Anonymous, disulfiram, naltrexone, acamprosate
• multivitaminsupplements(especiallythiamine)
• cautionwithdrugsmetabolizedbytheliver
• prednisoloneifseverealcoholichepatitisbasedonMaddrey’sdiscriminantfunctionorMELDscoreas
described in Prognosis
■ pentoxifylline less used since most definitive trial did not demonstrate efficacy
Prognosis
• Maddrey’sdiscriminantfunction(basedonPTandbilirubin)andMELDpredictmortalityandguide treatment (consideration for corticosteroids for severe disease based on Maddrey ≥ 32 or MELD ≥21)
• fattyliver:completeresolutionwithcessationofalcoholintake
• alcoholichepatitismortality
■ immediate: 30%-60% in the first 6 mo if severe ■ with continued alcohol: 70% in 5 yr
■ with cessation: 30% in 5 yr