Key Aspects of Diagnosing Alcoholic Hepatitis. Mark Sonderup University of Cape Town & Groote Schuur Hospital

Transcription

1 Key Aspects of Diagnosing Alcoholic Hepatitis Mark Sonderup University of Cape Town & Groote Schuur Hospital

2 42 year old woman, married with 3 children No significant co-morbidities or illnesses Habits Non smoker Non IDU or other substances Alcohol: consumed ± 1 bottle wine/day until end of 2012 ( New Years resolution )

3 Mid-November 2013 Developed a viral URTI ± 1 week later she reported increasing fatigue, jaundice and abdominal distention GP concerned about a clinical hepatomegaly and low grade fever Blood tests performed and patient referred to a HPB surgeon for evaluation (?malignancy)

4 o/e Markedly jaundiced Temp 38 o C CVS: BP: 130/70 P: 84, regular S 1 S 2 normal Respiratory: clinically normal Abdomen: Neuro: alert, no flap, no foetor

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7 Na 134 K 2.7 Urea 3.9 Creatinine 30 Mg 0.64 Total BR 140 Conj BR 78 ALP 145 GGT 492 ALT 22 AST 114 Alb 25 Hb 6.7 MCV 128 WCC 15.4 Platelets 116 INR 1.8 ferritin 576 U/S abdomen: no biliary dilation, coarsened hepatomegaly, PV patent, free fluid in abdomen MRI: Upper GI scope: LA grade D oesophagitis Vitamin B12, Folate, TSH = normal 77% neutrophils, PCT: 0,704

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9 I don t drink anymore, I stopped almost a year ago it was bad for me All I take is. 45% ETHANOL (100%) V/V 100ml bottles = 45g alcohol per bottle Patient drinking ~4 bottles a day = 180g ethanol per day

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15 37 year old woman HIV on cart X 2 months (AZT/3TC/ATV) CD4 405) Previous TB X 2 Presents to Infectious Diseases PUO Tender hepatomegaly Jaundice Workup US: increased echogenicity, hepatomegaly, modest ascites Bloods CXR: old TB changes Differential Diagnosis 1. TB IRIS 2. Lymphoma 3. Other TB IRIS preferred diagnosis Started on 70mg prednisone TB therapy emprically Proceed to Liver Biopsy (TB investigations all negative) Na 128 K 3.4 Urea 2.2 Creatinine 40 Total BR 126 Conj BR 91 ALP 94 GGT 236 ALT 14 AST 196 Alb 20 Hb 7.1 MCV 99 WCC 13.3 Platelets 233 INR 1.93 CRP 150

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20 Alcoholic Hepatitis! History of significant alcohol, binge drinking on weekends Drinking up to point of admission DF>32

21 Liver disease Spectrum of Hepatic Pathology Steatosis 10-35% Alcoholic Hepatitis 8-20% Cirrhosis Hepatocellular carcinoma Diehl AM 2006 Day C. Clinical Medicine 2005; 6: 19-25

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23 Continuum of alcoholic liver disease

24 Alcoholic Hepatitis Clinical syndrome of jaundice and liver failure viz. coagulopathy and/or encephalopathy Typically with chronic alcohol use (mean ~100 gm/day) rather than binge drinking Risk factors include: Amount of alcohol ingested (not a linear relationship); Female gender Genetic factors (risk in children of alcoholics) Protein calorie malnutrition/obesity Concomitant viral hepatitis e.g. HBV, HCV Despite abstinence - patients with severe AH have a 28 day mortality between 15 34%

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28 Basic Pathogenesis of AH Oxidative metabolism of ethanol to acetaldehyde generates reactive oxygen species, which induce lipid peroxidation, causing hepatocellular death via necrosis/apoptosis Increased endotoxin levels due to intestinal permeability leading to increased proinflammatory cytokines by activating Kupffer cells (e.g. TNF α levels are higher in pts with AH than in inactive cirrhosis)

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30 Alcoholic Hepatitis Clinical presentation at the bedside Classic features of liver disease often present Jaundice Fever Ascites Coagulopathy ± Encephalopathy Hepatomegaly (often tender) Mean years old Woman risk greater more often male

31 Classic lab diagnostic features 1. Liver profile and Chemistry Elevated AST and ALT (rarely > 300 IU/ml) AST/ALT > 2:1 (> 80% pts) Increased GGT (70-90% pts) - independent of liver disease Jaundice Elevated creatinine is an ominous sign (portends for HRS) 2. Haematology Leukocytosis with neutrophilia Increased MCV (80-100% pts) Coagulopathy

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33 Summary: Cornerstone of diagnosis History Detailed and thorough history remains key to the diagnosis Lengthy discussion may be needed - patients don t appreciate the amount of alcohol they consume Examination Fever (~50%), hepatomegaly (bruit in 59%), jaundice (100%) Lab data AST>ALT Increased WCC Biopsy Useful adjunct -transjugular approach required

34 Assessing Illness Severity Maddrey s Discriminant Function MELD Glasgow Alcoholic Hepatitis Score Lille model

35 Summary : Alcoholic Hepatitis AH is a clinical syndrome of inflammation of the liver with hepatocellular injury ± fibrosis Associated with often recent long-standing consumption of large amounts of alcohol Key to diagnosis is a combination of thorough history, bedside clinical features with supportive laboratory features Possible role for biopsy

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