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Time
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Learning Objective
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Response
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0:00 mins
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Welcome and formation of students into groups. Facilitator should assign students into groups and ask students to share the responses that were gathered individually and discuss the case discussion question.
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- Explain the epidemiology of alcoholic liver disease in the United States.
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- Is a leading cause of mortality, nearly 250,000 deaths attributed to ALD; about 4% prevalence (JAMA, May 2019);
- ALD leading indication for liver transplants (Clin Gastroenterol Hepatol. 2018;16(8):1356-1358.).
- About half of the deaths from cirrhosis are alcohol-related
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- List the risk factors for developing alcoholic liver disease.
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- Excessive alcohol use
- More common in men
- HCV
- obesity
- genetic
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- Describe how alcohol is normally metabolized by the liver.
Discuss with your group:
How did ethanol use lead to hepatitis in this patient?
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- by alcohol dehydrogenase (ADH)
- cytochrome P450
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0:20 mins
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Facilitator: Facilitate a debrief of the responses to the learning objectives and case discussion question with the entire class for 10 minutes.
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- Describe how the liver participates in blood clotting.
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- Hemostasis is related to liver function. Coagulation factors are synthesized by liver parenchymal cells and the liver’s reticuloendothelial system serves as important role in the clearance of activation products.
- Vitamin K dependent factors: Prothrombin (which we usually measure in the lab), factor VII, IX, X, protein C and S
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- Describe normal Starling pressures and changes that result in peripheral edema and ascites in a patient with alcoholic liver disease.
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Normal:
- Pc = capillary pressure
- Pi = interstitial fluid pressure
- πc = plasma colloid oncotic pressure
- πi = interstitial fluid colloid osmotic pressure
Edema:
- In this case, the peripheral edema is caused by decreased plasma proteins and increased interstitial fluid pressure.
- Ascites in this case is from increased portal pressures and the “weeping” of fluids off the surface of the liver.
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- List the normal progression of alcoholic liver disease.
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- Steatosis
- Steatohepatitis
- Cirrhosis
- Hepatocellular carcinoma
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0:50 mins
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Facilitate a debrief of the responses to the learning objectives and case discussion question with the entire class for 10 minutes.
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0:60 mins
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At 60 minutes: BREAK for 10 minutes
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1:10 mins
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Facilitator should assign students into groups and ask students to share the responses that were gathered individually and discuss the case discussion question.
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- List the signs and symptoms of alcoholic liver disease.
Discuss with your group:
What causes this patient’s peculiar breath (fetor hepaticus)?
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- Sometimes asymptomatic
- with cirrhosis – jaundice, weakness, edema, swollen abdomen, GI bleed
- evidence of hepatomegaly on physical exam
- ascites
- evidence of encephalopathy
- skeletal muscle wasting/weakness
- white discoloration of fingernails (leukonychia)
- gynecomastia
- testicular atrophy
- palmar erythema
- halitosis
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- Contrast liver function laboratory results from a patient with alcoholic liver disease to normal lab findings and to patients with other forms of liver disease.
Discuss with your group:
Why is bilirubin elevated in this case?
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- The aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio is >2 in ALD patients.
- ALT is often higher than serum AST in patients with other forms of liver disease.
- elevated transaminases in ALD patients
- elevated gamma-glutamyl transpeptidase (GGT) in patients with ALD (not specific to ALD)
- Blood findings in patients with ALD:
- Elevated bilirubin
- Thrombocytopenia
- Anemia
- Elevated MCV
- Decreased lymphocyte count
- Increased ESR
- Increased INR
- Radiographic image findings:
- Signs of hepatic steatosis
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- Determine the correct evaluation and testing to make a diagnosis for the patient in this case.
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- Determine alcohol consumption
- Physical exam – angiomata, ascites, gynecomastia, URQ tenderness
- Lab tests – discussed above
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1:30 mins
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Facilitate a debrief of the responses to the learning objectives and case discussion question with the entire class for 10 minutes.
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- Determine differential diagnoses for the patient in this case.
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- Hepatitis C, Hepatitis B
- NAFLD
- Wilson
- Acute liver injury
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- Develop a management scheme for the patient.
Discuss with your group:
What interventions have been proven effective to address alcoholism?
What social support is currently available in our community?
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- Counsel on alcohol intake
- What meds to prescribe?
- Counsel on diet and vitamin use
- Counsel on acetaminophen
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- Describe when patients need a liver biopsy.
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- Patient with abnormal serum aminotransferase that persisted for more than six months without a clear explanation.
- Patient with normal liver enzymes but BMI > 30
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1:50 mins
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Facilitate a debrief of the responses to the learning objectives and case discussion question with the entire class for 10 minutes.
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