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CASE STUDY ON

ALCOHOLIC LIVER

INTRODUCTION

LIVER
ALCOHOLIC LIVER
DISEASE
CASE STUDY

LIVER
Liver 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 wont


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 fibrosis
2. Destruction of vascular & biliary elements
3. Regeneration
4. 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 75100 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 alcoholinduced 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 ()

LFT
SGOT-169 microL ()
SGPT-162 microL ()
ALP 58 microL ()
Albumin 3.1 gm/dl ()
Globulin 21gm

RFT
BUN-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 Chart
S.N Drug Name
o

ROA

Frequency

Duration
10 11 12
13

Inj.Monocef (1g)
IV
(cephalosporinantibiotic
)

BD

Y
-

T.Udiliv(600mg)
(ursodeoxycholic acid)

po

TDS

- Y Y -

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

IV

BD

Y
Y

Tab.Hepameez(10mg)
(L-ornithine+ Laspartate)

PO

OD

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

IV

OD

_ Y

Syp.duphalac (2tsp)
Bisacodyl - laxative

PO

SOS

Y
Y

Y
_

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 Chart
S.N Drug Name
o

ROA

Frequency

Duration
10 11 12
13

Inj.Monocef (1g)
IV
(cephalosporinantibiotic
)

BD

Y
-

T.Udiliv(600mg)
(ursodeoxycholic acid)

po

TDS

- Y Y -

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

IV

BD

Y
Y

Tab.Hepameez(10mg)
(L-ornbthine+ Laspartate)

PO

OD

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

IV

OD

_ Y

Syp.duphalac (2tsp)
Bisacodyl - laxative

PO

SOS

Y
Y

Y
_

Y Y

Thank you

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