CASE STUDY ON ALCOHOLIC LIVER CIRRHOSIS

INTRODUCTION

•LIVER•ALCOHOLIC LIVER DISEASE•CASE STUDY

LIVERLiver is one of the largest organ in our body.,weighs upto 1500 grams in adults.With the exception of the brain, the liver is the most complex organ in the body And it has morethan 500 different vital functions in our body.

Some of the more well-known functions include the following:Production of bile, which helps carry away waste and break down fats in the small intestine during digestion

Production of certain proteins for blood plasma Production of cholesterol and special proteins to help carry fats through

the body Conversion of excess glucose into glycogen for storage (glycogen can

later be converted back to glucose for energy) Regulation of blood levels of amino acids, which form the building blocks

of proteins• Processing of haemoglobin for use of its iron content (the liver stores iron)• Conversion of poisonous ammonia to urea (urea is an end product of

protein metabolism and is excreted in the urine)• Regulating blood clotting• Resisting infections by producing immune factors and removing bacteria

from the bloodstream

• And yet, when your liver is damaged, you generally won’t know about it – until things get serious.

• Liver disease is defined as acute or chronic liver on the basis of whether the history of disease is lessthan/greater than 6months, respectively.

• The hepatocyte is the functioning unit of the liver.• Liver is the only organ which is readily regenerate.• Viral infections and paracetamol overdose are the leading

causes of acute liver disease, but a significant number of patients have no defined aetiology.

• Alcohol abuse and chronic viral hepatitis(B and C) are the major causes of chronic liver disease.

ALCOHOLIC LIVER CIRRHOSIS

Alcoholic liver disease is a term that encompasses the hepatic manifestations of alcohol overconsumption, including fatty liver, alcoholic hepatitis, and chronic hepatitis with hepatic fibrosis or cirrhosis.

 It is the major cause of liver disease in Western countries. Term was 1st coined by Laennec in 1826• Primary histologic features:

1. Marked fibrosis2. Destruction of vascular & biliary elements3. Regeneration4. Nodule formation

About Alcohol :• Alcohol beverage is a drink that contains ethanol• In the bloodstream, from the stomach, alcohol is absorbed between

5-10 minutes• Fact : females absorb alcohol faster than males because their bodies

contain less water Problem With Alcohol Beverages:• Alcohol beverages are being consumed everyday, but consuming too

much can bring problems• An example would be alcoholic liver disease(cirrhosis),heart

disease, cancer and strokes• Cause addiction

Stages Of ALD :There are three main stages of alcoholic liver disease, although there is often

an overlap between each stage. The three stages are explained below.

Alcoholic fatty liver disease• Alcoholic fatty liver disease is the first stage of alcoholic liver disease.• Drinking a large amount of alcohol, even for only a few days, can lead to

a build-up of fatty acids in the liver.• Fatty liver disease rarely causes any symptoms but it is an important

warning sign that you are drinking at a level that is harmful to your health.

• Fatty liver disease is reversible. If you stop drinking alcohol for two weeks, your liver should return to normal.

Alcoholic hepatitis• Alcoholic hepatitis (not related to infectious hepatitis) is the second,

more serious stage of alcoholic liver disease.

• Prolonged alcohol misuse over many years can cause the tissues of the liver to become inflamed. This is known as alcoholic hepatitis. Less commonly, alcoholic hepatitis can occur if you drink a large amount of alcohol in a short period of time (binge drinking).

• Alcoholic hepatitis is usually reversible, although you may need to stop drinking alcohol for several months or years.

Cirrhosis• Cirrhosis is the final stage of alcoholic liver disease. Cirrhosis happens when

prolonged inflammation causes scarring of the liver and loss of function. Loss of liver function can be life threatening.

• The damage caused by cirrhosis is not reversible. In mild to moderate cases, stopping drinking alcohol immediately should prevent further damage and lead to the gradual recovery of liver function. In more severe cases, a liver transplant may be required.

Epidemiology :• In india, liver cirrhosis is one of the leading cause of death .• 12th leading cause of death in the united states • On average about 27,000 deaths per year

• 40% cases asymptomatic

• Additional 10,000 deaths due to liver cancer secondary to cirrhosis

• Overall, alcoholic liver disease accounts for well over a third

(37%) of liver disease deaths. And figures show victims of liver

disease are getting younger – more than 1 in 10 of deaths of people

in their 40s are from liver disease, most of them from alcoholic

liver disease

Aetiology of liver cirrhosis

• Hepatitis C, fatty liver, and alcohol abuse are the most common causes of cirrhosis of the liver., but anything that damages the liver can cause cirrhosis, including:

• Fatty liver associated with obesity and diabetes• Chronic viral infections of the liver (hepatitis types B, C, and D;

Hepatitis D is extremely rare)• Blockage of the bile duct, which carries bile formed in the liver to

the intestines, where it helps in the digestion of fats; in babies, this can be caused by biliary atresia in which bile ducts are absent or damaged, causing bile to back up in the liver. In adults, bile ducts may become inflamed, blocked, or scarred, due to another liver disease called primary biliary cirrhosis.

• Repeated bouts of heart failure with fluid backing up into the liver

• Certain inherited diseases such as:– Cystic fibrosis– Glycogen storage diseases, in which the body is unable to

process glycogen, a form of sugar that is converted to glucose and serves as a source of energy for the body

– Alpha 1 antitrypsin deficiency, an absence of a specific enzyme in the liver

– Diseases caused by abnormal liver function, such as hemochromatosis, a condition in which excessive iron is absorbed and deposited into the liver and other organs, and Wilson's disease, caused by the abnormal storage of copper in the liver

• Although less likely, other causes of cirrhosis include reactions to prescription drugs, prolonged exposure to environmental toxins, or parasitic infections.

Risk Factors :• The risk factors presently known are:• Quantity of alcohol taken: consumption of 75–100 ml/day for 20 years or more in

men, or 25 ml/day for women significantly increases the risk of hepatitis and fibrosis by 7 to 47%

• Pattern of drinking: drinking outside of meal times increases up to 2.7 times the risk of alcoholic liver disease.

• Gender: females are twice as susceptible to alcohol-related liver disease, and may develop alcoholic liver disease with shorter durations and doses of chronic consumption. The lesser amount of alcohol dehydrogenase secreted in the gut, higher proportion of body fat in women, and changes in fat absorption due to the menstrual cycle

• Genetic factors: genetic factors predispose both to alcoholism and to alcoholic liver disease. Monozygotic twins are more likely to be alcoholics and to develop liver cirrhosis than dizygotic twins. Due to polymorphisms in the enzymes involved in the metabolism of alcohol.

• Iron overload (Hemochromatosis)• Diet: malnutrition, particularly vitamin A and E deficiencies, can worsen alcohol-

induced liver damage by preventing regeneration of hepatocytes. This is particularly a concern as alcoholics are usually malnourished because of a poor diet, anorexia, and encephalopathy.

Signs

• Bleeding tendencies : deficiency of clotting factors • Hyperpigmentation• Hyperdynamic circulatory state• Edema• Hernia• Testicular atrophy• Delirium• Constructional apraxia• Flapping tremors• Inversion of sleep rhythm

Symptoms

Symptoms vary based on how bad the disease is. You may not have symptoms in the early stages. Symptoms tend to be worse after a period of heavy drinking.

Digestive symptoms include:• Pain and swelling in the abdomen• Decreased appetite and weight loss• Nausea and vomiting• Fatigue• Dry mouth and increased thirst

Skin problems such as:• Yellow color in the skin, mucus membranes, or eyes (jaundice)• Small, red spider-like veins on the skin• Very dark or pale skin• Redness on the feet or hands• Itching

Brain and nervous system symptoms include:• Problems with thinking, memory, and mood• Fainting and lightheadedness• Numbness in legs and feet

Diagnostic tests

• Complete blood count (CBC)• Liver biopsy• Liver function tests• Abdominal CT scan• Blood tests for other causes of liver disease• Ultrasound of the abdomen

And patient social history plays a vital role to determine the disease.

Treatment

• The first treatment of alcohol-induced liver disease is cessation of alcohol consumption. This is the only way to reverse liver damage or prevent liver injury from worsening. Without treatment, most patients with alcohol-induced liver damage will develop liver cirrhosis

• Counseling may be necessary to break the alcohol addiction. • Vitamins, especially B-complex and folic acid, can help reverse

malnutrition.• Diet • Liver transplantation

Case Study• A 70 years old male patient was admitted in the hospital on 10/07/12

Chief Complaints :

C/o: abdominal distention since 4days

weakness since 15days

decreased appetite since 15days

weight loss since 15days

On Examination : Patient is conscious and oriented No cyanosis/icterus/clubbing B.P-120/80 mm Hg RR-20 b/m PR- 80b/m CVS-S1S2 +ve

Patient Medical History :Not a k/c/o : HTN\BA\DM

Past Medication History :Not available

Social History :Alcoholic,

Smoker,

Belongs to low economic status,

Married ,

Non-Allergic

Lab Investigations• CBC

Hb – 12g/Dl (↓)

RBC – 3.2 M/micro L (↓)

WBC – 6700 /mm3

ESR – 20mm/hr (↑)

• LFTSGOT-169 microL (↑)

SGPT-162 microL (↑)

ALP – 58 microL (↑)

Albumin – 3.1 gm/dl (↓)

Globulin – 21gm

• RFTBUN-12mg/dL

Sr.Cr-0.7mg/dL

• Special investigations Hbs Ag : -ve (impression)

US Abdomen : coarse texture

Gall Bladder : wall thickening

Spleen : enlarged mass

Diagnosis :Alcoholic liver cirrhosis

Drug ChartS.No Drug Name ROA Frequency Duration

10 11 12 13

1 Inj.Monocef (1g)(cephalosporin–antibiotic )

IV BD Y Y - -

2 T.Udiliv(600mg)(ursodeoxycholic acid)

po TDS - Y Y -

3 Inj.pantoprazole(40mg)(proton pump inhibhitors)

IV BD Y Y y Y

4 Tab.Hepameez(10mg)(L-ornithine+ L-aspartate)

PO OD Y Y Y Y

5 Inj.Metronidazole(160mg)(anti-eleminthic)

IV OD _ Y _ _

6 Syp.duphalac (2tsp)Bisacodyl - laxative

PO SOS Y Y Y Y

7 Inj.Amikacin(250mg) IV BD _ _ Y Y

SOAP NOTES

• SUBJECTIVE :

A 7OYrs old male patient was admitted in the hospital on 10/7/12, with c/o: abdominal distension since 4days, weakness since 15days, decreased appetite since 15days, weight loss since 15days,past medical & medication history nil, Social history -Alcoholic, Smoker, Belongs to low economic status, Married , Non-Allergic.

• OBJECTIVE :

patient was to be found, abnormalities of LFT, CBC& social history &US Abdomen : coarse texture, Gall Bladder : wall thickening, Spleen : enlarged mass.

• Assessment :

Based upon the above abnormalities,patient was assessed to be suffering from alcoholic liver cirrhosis.

• Plan :

Refer to Drug Chart

Drug ChartS.No Drug Name ROA Frequency Duration

10 11 12 13

1 Inj.Monocef (1g)(cephalosporin–antibiotic )

IV BD Y Y - -

2 T.Udiliv(600mg)(ursodeoxycholic acid)

po TDS - Y Y -

3 Inj.pantoprazole(40mg)(proton pump inhibhitors)

IV BD Y Y y Y

4 Tab.Hepameez(10mg)(L-ornbthine+ L-aspartate)

PO OD Y Y Y Y

5 Inj.Metronidazole(160mg)(anti-eleminthic)

IV OD _ Y _ _

6 Syp.duphalac (2tsp)Bisacodyl - laxative

PO SOS Y Y Y Y

7 Inj.Amikacin(250mg) IV BD _ _ Y Y

Thank you…