This is a lecture note for 5th semester MBBS students. Lecture notes on hepatology, liver disease, alcoholic liver disease, alcohol-related liver disease, alcoholic hepatitis, portal hypertension, ascites. Introduction to ascites and management of ascites.

1. Hepatology lectures for
5th Sem;MBBS
Pratap Sagar Tiwari
MBBS,MD (Medicine),DM (Hepatology)

2. ALCOHOL-R LIVER DISEASE
AUD
1
2
3
Alcoholic Steatosis
4 Cirrhosis
Alcoholic Hepatitis

3. Introduction: Alcohol-related liver disease
• Alcohol-related liver disease includes a variety of clinical disorders: alcohol-related
steatosis, alcoholic hepatitis (AH), alcohol-related cirrhosis (AC), and AC complicated by
hepatocellular carcinoma (HCC).[AASLD19]
Alcohol-related steatosis
Alcoholic hepatitis (AH)
Alcohol-related cirrhosis (AC)
AC complicated by hepatocellular carcinoma (HCC)
3

4. INTRODUCTION
Acc to NIAAA: The consumption of 40–80 g/day of alcohol in men and 20–40 g/day of alcohol in women for 10–12 years
is required for significant risk of liver disease.[5]
A simplification would be to adopt the European standard (also WHO) that one standard
measure of any form of alcohol is constituted by 10 g.
A standard drink contains 10 g alcohol = 300 ml beer, 100 ml wine = 30 ml whiskey
A recent analysis suggesting alcohol use should be limited to one drink per day for men
and women, or even that any drinking may have adverse health consequences.
Furthermore, the NIAAA defines binge drinking as a pattern of drinking that brings blood
alcohol concentration (BAC) levels to 0.08 g/dL, and which typically occurs after 4 drinks
for women and 5 drinks for men—in about 2 hours.

5. ALCOHOL USE DISORDER (AUD)
• Alcohol use disorder (AUD) is a medical condition characterized by an impaired ability
to stop or control alcohol use despite adverse social, occupational, or health
consequences.
• It encompasses the conditions that some people refer to as alcohol abuse, alcohol
dependence, alcohol addiction, and the colloquial term, alcoholism.
• Considered a brain disorder, AUD can be mild, moderate, or severe.

7. FACTORS AFFECTING THE RISK OF A-r LD

9. ALCOHOLIC HEPATITIS (AH): INTRODUCTION
• AH is a clinical syndrome occurring in pts with chronic and active heavy alcohol use.
• Pts present with jaundice and systemic inflammatory response syndrome (SIRS) and may
progress to acute-on-chronic liver failure.
• Pts with severe AH have mortality of up to 30–40% at 28 days from the initial
presentation.
9
NOTE: SIRS is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute
inflammation, ischemia or reperfusion, or malignancy, to name a few) to localize and then eliminate the endogenous
or exogenous source of the insult.
It involves the release of acute-phase reactants, which are direct mediators of widespread autonomic, endocrine,
hematological, and immunological alteration in the subject.
Even though the purpose is defensive, the dysregulated cytokine storm can cause a massive inflammatory cascade
leading to reversible or irreversible end-organ dysfunction and even death.

10. ALGORITHM FOR DX OF ALCOHOLIC HEPATITIS
*Clinical criteria: Heavy alcohol use (>40
g/d: females and >60 g/d: males) for ≥6
mnths; Active alcohol use until at least 8
weeks prior to presentation; Recent (<1
month) onset or worsening of jaundice;
Exclude other confounding factors.
*Biochemical criteria: Serum bilirubin
>3 mg/dl, AST >50 and <400, AST >ALT by
1.5:1;
**Transjugular route preferred for obtaining
the liver tissue.
**Characteristic histological findings: Cell ballooning, neutrophil infiltration, cholestasis, varying degree
of steatosis and fibrosis.
***Needed for inclusion in clinical trials and before starting specific pharmacologic therapy.
1. Kamath PS, Singal, Louvet et al. Grand Rounds: Alcoholic Hepatitis.Journal of Hepatology 2018 vol. 69 j 534–543
10

11. RISK STRATIFICATION
• At admission, the two most widely used scores are the MDF and the MELD score.
• Severe AH is DX if the MDF score is ≥32 or the MELD score is ≥20.
11

12. GLASGOW ALCOHOLIC HEPATITIS SCORE/ABIC
• The GAHS uses age, white cell count, urea, PT or INR, and serum bilirubin.
• A value between 5 and 12 is obtained with a score ≥9 predicting a poor outcome.
12

13. DRUGS
➢The optimum RX of sAH (MDF > 32) has been debated for some time.
➢The STOPAH study was a large, multicentre, double-blind, RCT to evaluate the merits of
glucocorticoids and/or a weak anti-TNF agent (pentoxifylline), alone or in combination.
➢In a cohort of 1103 pts, no significant benefit from pentoxifylline RX was identified but
treatment with prednisolone (40 mg/d for 28 days) led to a modest reduction in short-
term mortality, from 17% in placebo-treated pts to 14% in the prednisolone group.
➢These findings were consistent with earlier studies where an improvement in 28-day
survival from 52% to 78% is seen when STEROIDS are given to those with Glasgow score
>9.
➢Neither STEROIDS nor pentoxifylline improved survival at 90 days or 1 year, however.
➢Sepsis is the main side-effect of glucocorticoids, and existing sepsis and variceal
haemorrhage are the main contraindications to their use.
➢If the bilirubin has not fallen 7 days after starting glucocorticoids, the drugs are unlikely
to reduce mortality and should be stopped.

14. ALGORITHM FOR OPTIMAL MX OF AH
*Using Lille score. **Excellent psychosocial support in a patient with first episode of AH.
AH, alcoholic hepatitis; ICU, intensive care unit; LT, liver transplantation; OF, organ failure. 14

15. TREATMENT SUMMARY
Proven benefit Likely benifit Potential benefit Unlikely benifit Others
Abstinence Nutrition
Steroids
NAC
Regeneration therapy
Pentoxifylline (PTX)
Propylthiouracil (PTU)
S-adenosyl-L-methionine (SAM)
INSULIN
GLUCAGON
TNF-a
FMT

16. LIVER TRANSPLANTATION
➢The role of LT in the management of ALD remains controversial.
➢The challenge is to identify patients with an unacceptable risk of returning to harmful
alcohol consumption.
➢Many programmes require a 6-month period of abstinence from alcohol before a
patient is considered for LT.
➢The outcome of LT for ALD is good and if the patient remains abstinent there is no risk
of disease recurrence.
➢Transplantation for alcoholic hepatitis has been thought to have a poorer outcome and
is seldom performed due to concerns about recidivism; studies to quantify this are
ongoing.