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Acizi grasi
acetat cetoza
trigliceride
diagnosis
Ficatul gras alcoolic
caracteristici
diagnostic
Alcoholic hepatitis
Necroinflammatory lesions of varying
degrees associated with lesions
of of steatosis
can be reversed, but it is a more
serious injury than alcoholic fatty liver
most important precursor of alcoholic
cirrhosis
Alcoholic hepatitis
Epidemiology
prevalence unknown
necropticall studies. 10-35% of patients
hospitalized has alcoholic hepatitis
50% of cases has associated cirrhosis
diagnostic difficulties
Alcoholic hepatitis
pathology
Score 1 2 3
Age <50 50
WCC <15 15
Urea (mmol/l) <5 5
PT ratio <1.5 1.52.0 2
Bilirubin (mg/dl) <7.3 7.314.6 >14.6
Poor prognosis if score >8 (for score calculated on hospital day 1 or day 7)
Alcoholic hepatitis
long term prognosis
chronic disease with clinical, laboratory and
histological abnormaliyies persisting for months
Evolution to livr cirrhosis in> 50% of cases
Pronostic factors
Severity of fibrosis = an important prognostic
factor
minimal fibrosis causes a 5-year survival rate of
72%
Severe fibrosis determines survival rate at 5 years
only 48%
Coexistence of cirrhosis = a poor prognosis
Extension of inflammation = poor prognosis
Alcoholic hepatitis
the most important precursor to cirrhosis
In other studies:
rate of progression to cirrhosis even reached 80%
of those who stopped / reduced alcohol consumption,
70% returned the normal,
15% remained with alcoholic hepatitis,
15% developed cirrhosis;
mortality rate of 24% in 7 years
those who continued to drink too much alcohol,
mortality rate of 50% in seven years,
Alcoholic cirrhosis
diagnostic
Alcoholic cirrhosis
Main feature:
deposition of collagen and other proteins
(extracellular matrix) around hepatocytes,
with nodular regeneration
End-stage of alcoholic liver disease
Alcoholic cirrhosis
manifestari clinice
fairly wide spectrum:
about 10-20% are asymptomatic
commonly, patients present with classical painting with
complications and stigmata of chronic liver disease
sometimes liver disease is detected at an assessment related to
an event unrelated to liver disease
male hypogonadism and feminization are much more
common than in those with hemochromatosis or viral
cirrhosis
Alcoholic cirrhosis complications are similar to those of
any form of cirrhosis:
ascites, spontaneous bacterial peritonitis, hepatorenal
syndrome, hepatic encephalopathy, hepatocellular carcinoma
faecal
Alcoholic cirrhosis
laboratory data
Liver test abnormalities are less
pronounced than in alcoholic hepatitis,
many are within normal limits
moderate increases in AST and ALT
low levels of albumin
elevated serum globulins (more than 4 g / dL)
elevated serum levels of IgG and IgA
prolonged prothrombin time
thrombocytopenia, anemia
Alcoholic cirrhosis
positive diagnostic
Two traps:
(1) lack of consideration of alcoholic liver
disease in patients who do not fit into the
profile of chronic alcoholic
(2) the assumption that abnormal liver
function tests in an alcoholicpatient are
strictly related to alcoholic liver disease
Alcoholic cirrhosis
differential diagnosis
cirrhosis of other etiologies
other pathological conditions that can
mimic cirrhosis
constrictive pericarditis,
Budd-Chiari sd., veno-occlusive disease,
idiopathic PHT, MMM
chronic active hepatitis
Alcoholic cirrhosis
prognostic and evolution
PROGNOSTIC
better for. abstinent (60% survived 5 years compared with
40% of those who continued to drink)
better male> female
! poor prognosis: cholestasis, encephalopathy, ascites,
hypocoagulation, anemia, hyperazotaemia,
SURVIVAL
5-year survival is highly variable:
90% in those patients who have ascites, jaundice or HDS,
remaining abstinent
70% of those who continue to use alcohol and without
complications above
50% in those with jaundice or ascites, but are abstinent
30% of those who develop jaundice or ascites and continue
to drink
Liver cancer
Alcohol can be incriminated in the development of HCC.
The idea that alcohol is carcinogenic agent was postulated, but
the presence of liver cirrhosis appears to be important for the
development of liver cancer.
Intervention may be
direct - various mechanisms (oxidative stress, production of
acetaldehyde which is mutagenic, DNA methylation
abnormalities by decreasing glutathione, increased iron
intrahepatocitar, altered gene expression)
Indirect - by stimulating the action of various environmental
carcinogens (viruses, aflatoxin, vinyl chloride), or by decreasing
immune tolerance neopalzice
association of alcohol with chronic viral infections (HCV) causes
a synergistic effect in the development of HCC.
there is a relationship between HCC and dosage, HCC
does not appear at doses below 50 g alcohol / day, and
under 10 years of consumption.
treatment
1. abstinence
Steatoza alcoholic steatosis can be
completely reversible within several weeks
Persistence of alcohol intake is an
independent risk factor for poor prognosis in
cirrhosis
Take care of withdraw sd !!!
2. nutritional support
Malnutrition is an independent risk factor for
poor prognosis in alcoholic hepatitis
In 30 days
2%decease if mild malnutrition
52% deceseif severe malnutrition
Enteral or parenteral nutrition according to
severity
1g/kg additional protein, calories 2000 kcal / day,
vitamins (B1, B2, B6, C, E, K)
3. corticosteroids
Mec action: immunosuppressive, anti-inflammatory
and antifibrotic
indication alcoholichepatitis
Adm.
Oral - prednisolone 40 mg / day, 28 days
Parenteral - 32 mg / day,
Survival at 30 days
85% of CS
64% without CS
CI gastrointestinal hemorrhage, infections, kidney
failure
Val BT to 7 days medium term prognostic factor
84% suypravietuire if BT low-day 7 (6 months)
23% guardi if BT persist
Pentoxifylline
Phosphodiesterase inhibitor that decreases TNF
alpha
Dose 400 mg * 3/day
Recommended ethanolic hepatitis moderate,
severe
The benefit seems to be related to the decrease the
rate of complications related hepatorenal syndrome
decreases overall mortality of this complication
anti TNF alfa drugs
Infliximab
5 mg / kg single dose or 0,2,4 weeks
Being evaluated for severe forms of hepatitis
ethanolic
Promising results decreases mnortality
Relatively well tolerated?
Etanercept
Under evaluation, can not yet be recommended
outside clinical trials
Vit E
antifibrotic mechanisms
1000 UI/zi
Recommendedt in moderate forms
Debatable benefit
Sylimarine
Antioxidant, antifibrotic ?
Recommended in cirrhotic alcoholics
140 450 mg/zi long term
Debatable benefit but no adverse reactions
S-adenosyl-methionine
Decreases oxidative stress and increases glutathione
levels
Dose of 1200 mg / day 2 years at initial stages
ciroticii
Inconclusive results for now
Dilinoleoylfosfatidilcolina
Antifibrotic
under evaluation but so far are not conclusive results
Colchicine
Anti inflammatory and antifibrotic
Dose 1 mg / day, the long
Not proven effective, but shows adverse events
can not be recommended
hepatic transplantation
A long period was not accepted on the transplant list
useful for alcoholic cirrhosis with Child score C
Better prognosis if abstinent
about one third of patients started to drink after transplant
Recom
Minimum 6 months of abstinence
Capability of social reinsertion
Psychiatric approval
Absence of alcohol-induced extrahepatic pathology
(neurological, pancreatic, etc.)
Participation in special programs for alcohol addicts