alcoholoc liver disease

ALCOHOL INDUCED LIVER DISEASE

Presented By: NAGARAJU B

Alcohol induced liver diseases 2

India : alcohol

The prevalence of use of alcoholRanges from a low of 7% in Gujarat, to 75% in Arunachal Pradesh.

The per capita consumption is 4 lit/adult/yearIt accounts for 50% of CLD

ALD cause of mortality M: 11/100000 F:6/100000


Symptoms of Alcoholic Liver Disease may not appear until the condition is relatively advanced. They vary with the severity of the disease and worsen after a bout of heavy drinking.

Alcoholics are at an increased risk for gastrointestinal disorders, heart diseases and high blood pressure. Excessive alcohol use can also cause peptic ulcers, aggression, anxiety and depression.

A number of cancers can be developed as a result of alcoholism. Cancer of mouth, throat, oesophagus, stomach and liver are the few commonly- occurring ones.


Common symptoms: Dry mouth

Fatigue/nausea /loss of appetite Swollen abdomen due to an enlarged liver Pain in the abdomen Jaundice/ fever/Pallor Weight loss Fluid build-up in legs (oedema) and abdomen in case of cirrhosis Pain/numbness in hands and legs Hypo /hyper pigmentation on the skin Small spider like blood vessels on skin Red colouration on hands /feet Yellow colouration of skin /eyes in case of jaundice Bloody faeces Bleeding nose /gums Vomiting blood Changing moods /confusion/hallucinations/decreased alertness Impaired memory /poor judgment


Serious complications of alcohol consumption:

It include advanced diseases such as brain damage (Alcoholic Encephalopathy) and hypertension (high blood pressure within the liver).

The disease usually affects those who are older than 30 years.


Liver Liver is the Largest solid organ, Largest Gland, Main Metabolic organ of the Body

The liver is located in the upper right-hand portion of the abdominal

cavity, beneath the diaphragm, and on top of the stomach, right kidney,

and intestines. Shaped like a cone, the liver is a dark reddish-brown

organ that weighs about 3 pounds.

Liver is Made up of different cell types however 4 important cell types are discussing here Hepatocytes, Endothelial cells Kupffer cell Stellate cell


Hepatocytes:

They are rich in Organelle such as ER,

Golgi complex, Mitochondria.

Function:Participate in Protein, Carbohydrate & Lipid

Metabolism.Produce serum protein such Albumin, Coagulation

factor, Trasferrin.Endothelial cells:Sinusoidal endothelial cell lines the walls of hepatic

sinusoid.

Function: Filtration due to presence of Fenestration.


Kupffer cell:

They are located within sinusoidal cell.

Upon activation they secrete Inflammatory mediator: Cytokine

Function: PhagocytosisStellate cell: Play central role in storage of Vitamin

A(Retinol).

Overall functions of Liver: As a Detoxifying Organ As a Metabolic Organ As an Immunological Organ, As an Emulsifying agent(Bile salts) Producing Organ.


ALCOHOL

Ethanol: is a small two carbon alcohol that, due to its small size and alcoholic hydroxyl group is soluble in both aqueous and lipid environments.

This allows ethanol to freely pass from bodily fluids into cells.

Since the portal circulation from the gut passes first through the liver, the bulk of ingested alcohol is metabolized in the liver.

The process of ethanol oxidation involves at least three distinct enzymatic pathways.


Alcohol dehydrogenase

Microsomal ethanol oxidizing system (MEOS) which involves the cytochrome P450 enzyme CYP2E1 and requires NADPH instead of NAD+ as for ADH. The MEOS pathway is induced in individuals who chronically consume alcohol.

Fatty acid ethyl ester (FAEE) synthase. This latter pathway results in the formation of fatty acid ethyl esters and takes place primarily in the liver and pancreas, both of which are highly susceptible to the toxic effects of alcohol.

Acute Effects of Ethanol Metabolism The metabolism of ethanol via the CYP2E1 pathway results in increased ROS

production, including superoxide, hydrogen peroxide (H2O2), and hydroxyl radicals.

ROS production is associated with cancer development, atherosclerosis, diabetes, inflammation, aging, and other harmful processes.

The cell regulates ROS levels via numerous defense systems involving a variety of different antioxidant compounds (e.g. glutathione, GSH).

During ethanol oxidation ROS production increases dramatically due to induction of CYP2E1 and by activation of Kupffer cells in the liver. Both acute and chronic alcohol consumption can increase ROS production and lead to oxidative stress.



Chronic Effects of Ethanol Metabolism

In addition to the negative effects of the altered NADH/NAD+ ratio on hepatic gluconeogenesis, fatty acid oxidation is also reduced as this process requires NAD+ as a cofactor.

Concomitant with reduced fatty acid oxidation is enhanced fatty acid synthesis and increased triacylglyceride production by the liver.

In the mitochondria, the production of acetate from acetaldehyde leads to increased levels of acetyl-CoA. Since the increased generation of NADH also reduces the activity of the TCA cycle, the acetyl-CoA is diverted to fatty acid synthesis.

The reduction in cytosolic NAD+ leads to reduced activity of glycerol-3-phosphate dehydrogenase (in the glycerol 3-phosphate to DHAP direction) resulting in increased levels of glycerol 3-phosphate which is the backbone for the synthesis of the triglycerides.

Both of these two events lead to fatty acid deposition in the liver leading to fatty liver syndrome and excessive levels of lipids in the blood, referred to as hyperlipidemia.

Because ethanol metabolism by ADH and ALDH occurs essentially only in the liver, any of the adverse effects described above that are associated with ethanol metabolism by these enzymes, and the associated ROS production, primarily affect that organ.


In contrast, CYP2E1 is found in many tissues in addition to the liver, including the brain, heart, lungs, neutrophils, and macrophages.

Accordingly, metabolic consequences of CYP2E1-mediated ethanol oxidation will affect numerous tissues. The harmful effects associated with CYP2E1-mediated ethanol metabolism are primarily related to the production of ROS, mainly superoxide and hydroxyl radicals.

In the liver, the oxidative stress resulting from CYP2E1-mediated ethanol metabolism plays an important role in alcohol-related development of liver cancer.


Chronic ethanol consumption and alcohol metabolism also negatively affects several other metabolic pathways, thereby contributing to the spectrum of metabolic disorders frequently found in alcoholics.

These disorders include fatty liver syndromes such as NAFLD and NASH, hyperlipidemia, lactic acidosis, ketoacidosis, and hyperuricemia.

The first stage of liver damage following chronic alcohol consumption is the appearance of fatty liver, which is followed by inflammation, apoptosis, fibrosis, and finally cirrhosis.

.

Methanol


In the home, methanol is most frequently found in the form of "canned heat" or in windshield-washing products. Poisonings occur from accidental ingestion of methanol-containing products or when it is misguidedly ingested as an ethanol substitute.

Methanol poisoning causes visual disturbance, frequently described as "like being in a snowstorm.

Methanol (methyl alcohol, wood alcohol) is widely used in the industrial production of synthetic organic compounds and as a constituent of many commercial solvents.


BEVERAGES

Beverage Alcohol(%)Beer(12 oz) 5%Wine(4 oz) 12%Hard liquor (1.5 oz) 40% (Brandy,Whisky,Rum)

Local brew Arrack 40-50 Toddy 5-10


Risk for the development of ALD.

Time to develop ALD = to amount of alcohol consumed

Men: 60-80 gm/day for 10 yearsWomen:20-40 gm/day for 10 years

Alcoholic cirrhosis,Develops ONLY in 10 to 20% of those who are chronically heavy drinkers.


SIMPLE CONVERSION

BEER: ml/25WINE: ml/10 Gms of alcoholHARD LIQOUR : ml/3



ALCOHOL ABUSE VS. ALCOHOL DEPENDENCE

ALCOHOL abuses as those who drink despite recurrent social, interpersonal, and legal problems

Dependence- presence of 3 or more symptoms

a) Toleranceb) Withdrawal symptomsc) Loss of control over drinkingd) Strong desire to drinke) Drinking despite harm


DETECTION OF ALCOHOL ABUSE

CAGE(Cut down,annoyed by criticism, guity about drinking, Eye-opener in the morning)

AUDIT (Alcohol use Disorders Identification Test) 10-item questionnaire


CLINICAL FEATURES

SYMPTOMS PHYSICAL EXAMINATION

Jaundice stigma of CLDFatigue Tender hepatomegalyAnorexia HepaticWeight loss decompensationFever Ascities,Pain in RHC Eso.varies Encephalopathy.


LAB

Both AST and ALT are INC., <300IU/ml

AST>ALT of 2 (80%)Inc in GGTMacocytosis with anemiaThrombocytopeniaLeukocytosis –correlates with degree of injury.

Increasing Bilrubin and PT correlate with severity of liver disease


OTHERS….

•High CDT•High gamma globulin (IGA)•High uric acid •High serum lactate•Low albumin •High triglycerides


Life style Medication

EtoH intake : 80% survival rate in those who abstain

Smoking: Cigarette smoking is an independent risk factore for cirrhosis in ALD

Obesity


NATURITION THERAPY

Nutritional supplement improves hepatic function, and out come in AH,

•Patients consuming > 3000kcal/d had virtually no mortality,•Whereas those consuming <1000 kcal/d had > 80% 6-month mortality


DRUGS



CorticosteroidsDecrease the immune responseAnti inflammatoryAntifibriticIncrease production of albuminImprove ascitesImprove caloric intake by improving appetite


Prednisolone: 32 mg Po for 4 week followed by taper

Active form prednisolone, rather than the in active precursor prednisone, is preferred

No long term survival benefits


Pentoxifylline

It attenuates TNF-a release and actionExertes an antifibrinogenic action Lower portal hypertentionDecrease blood viscosityImprove organ microcirculation Tissue Oxygenation


Side-effects: Epigastric pain, vomiting, and dyspepsia

Dose: 400 mg TID

Improvement in short-term (4-week)Survival

Decrease in the rate of development of hepatorenal syndrome


Antioxidants:

s-adenosylmethionine: Benefits of SAM in ALD include roles as an Antioxidant Critical methyl donor Decreasing TNF levels, and Glutathionine


Propylthiouracil:

No siginificant effects of PTU vs Placebo on mortality, complications of liver disease

Colchicine:

No beneficial effect on overall mortality


Newer Approaches

PolyenylphosphatidylcholineN-Acetyl cysteineCombinational therapyLiver transplantation:OLT for alcoholic hepatitis is not currently recommended.


CONCLUSION All Alcoholic patients should be screened for

alcoholic liver disease. The diagnosis of alcoholic liver disease requires a detailed patient history, with supportive laboratory and imaging studies.

Liver biopsy may be useful to confirm the diagnosis, rule out other diseases, and prognosticate. All patients with alcohol-related liver disease should abstain from alcohol.

For those with severe disease and no contraindications to their use, steroids should be considered. Liver transplantation remains an option for select patients with end-stage liver disease due to alcohol.

Thank you

alcoholoc liver disease

Health & Medicine

high blood

chronic alcohol

alcoholic

hydroxyl radicals

increased

ros production

ethanol metabolism

disease