Risk Factors
- highest risk w/ > 120g ETOH/day (1 drink = 14 g) – 5.7% point prevalence
- 30-60 g ETOH/day = 1% point prevalence
Clinical Findings
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Jaundice + liver failure after years of ETOH abuse, typically 40-60 yo
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Key clinical finding: rapid onset of jaundice
- other findings: fever, ascites, proximal muscle loss, encephalopathy (severe cases)
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Labs: AST:ALT > 2
- Incr. Cr = indication of hepatorenal syndrome and poor prognosis
- Expect to have months to years of ascites and hepatic encephalopathy after ETOH abstinence
- If continued jaundice or onset of renal failure after abstinence – bad news
Histology
- Mallory Bodies: amorphous eosinophilic inclusion bodies
- Steatosis: presence of large fat globules in hepatocytes
- Intrasinusoidal Fibrosis: fibrosis in space between endothelial cells and hepatocyte
Mechanism
- ETOH -> Acetaldehyde -> Acetate
- Oxidative metabolism generates reducing equivalents (reduced NAD which is NADH)
- Incr. NADH blocks fatty acid oxidation & TCA -> Incr. Lipids
- Gut permeability: altered by ETOH which leads to incr. LPS-endotoxin systemically
- LPS + Binding protein activate CD14 on Kupffer cells -> activation
- Kupffer Cell Activation (LPS + CD14 binding): activates CD14 + TLR4 + MD2
- Downstream actiation of EGR1 (activates TNF-Alpha), NF-kB, TRIF
- Absence of EGR1 prevents ETOH-induced liver injury in mice
- Downstream actiation of EGR1 (activates TNF-Alpha), NF-kB, TRIF
- Activation of Kupffers leads to free radical production via CYP450 2E1
- Mitochondrial damage, endoplasmic reticulum apoptosis and lipid synthesis
- TNF-Alpha = key mediator of hepatocellular injury
- Decr TNF-R1 = decr. TNF-alpha
- Seems to target mitochondria -> release of mitochondria cytochrome c & fas ligand
- Leads to hepatic apoptosis & sensitivity to natural killer T cells
Diagnosis
- Key Findings: AST:ALT > 2, T Bili > 5, Incr. INR, incr. neutrophils + ASCITES & HX ETOH ABUSE
- Differential: NASH, viral hep (acute or chronic), toxins, Wilson’s (fulminant), autoimmune, A1AT deficiency, pyogenic hepatic abscess, ascending cholangitis, HCC decompensation
- Bx is helpful but NOT required for dx or prognosis
- Screen for bacterial infection: PNA, SBP, UTI
Assessing Severity
- Maddrey’s, Glasgow and MELD are 3 scores
- MELD: assesses pt risk of death while waiting for txp
- Score 21 or greater: 90 day mortality of 20%
Treatment
- Issues to Address
- 1) Ascites: sodium restriction, diuretics
- 2) Hepatic Encephalopathy: lactulose, gut cleansing abx (Rifampin)
- 3) Vitamin deficiencies: thiamine
- 4) Delirium Tremens: benzodiazepines
- 5) Hepatorenal Syndrome: monitor creatinine, albumin + vasoconstrictors (ex. terlipressin, midodrine & octreotide, norepinephrine)
- Abstinence: most important aspect of tx – psych support, role for baclofen?
- Corticosteroids: may reduce inflammation in VERY SEVERE CASES ONLY
- MOA: inhibit activator protein 1 and NF-kB, reduction in proinflammatory cytokines (ex. IL-8, TNF-alpha)
- Prednisolone 40mg QD x 28 days
- Indications: Maddrey’s score of 32 or MELD of 21 or greater
- Calculate Lille score after 7 days of tx – score > 0.45 = no response to steroids & 6 month survival < 25% – unresponsive in 40% steroid cases
- Pentoxifylline (phosphodiesterase inhibitor): one RCT showing reduced short-term mortality
- May have a role in decreasing incidence of hepatorenal syndrome
- What not to give
- TNF-Alpha inhibitors (Infliximab, Etanercept): may incr. mortality 2/2 infxn
- Anabolic steroids: no benefit
- Antioxidants: no benefit
- Colchicine, PTU, Insulin & Glucagon: no benefit
- Liver Txp: technically a 6 month wait period of abstinence, but need to eval if mortality is expected to be less than 6 months
Source: NEJM – Alcoholic Hepatitis