barcelona . spain - European Association for the Study of the Liver
barcelona . spain - European Association for the Study of the Liver
barcelona . spain - European Association for the Study of the Liver
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BARCELONA . SPAIN<br />
90 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 91<br />
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012<br />
NOTES<br />
REFERENCES:<br />
PATHOGENESIS:<br />
Cheng J.Mechanisms <strong>of</strong> Alcohol-Induced Endoplasmic Reticulum Stress and Organ Injuries.<br />
Biochem Res Int 2012; 2012: 216450.<br />
Seth D, D’Souza El-Guindy NB, Apte M, Mari M, Dooley S, Neuman M, Haber PS, Kundu GC et<br />
al. Alcohol, signaling, and ECM turnover. Alcohol Clin Exp Res 2010 34(1):4-18.<br />
Wang HJ, Zakhari S, Jung MK. Alcohol, inflammation, and gut-liver-brain interactions in tissue<br />
damage and disease development.World J Gastroenterol 2010; 16(11):1304-1313.<br />
Shimizu Y. <strong>Liver</strong> in systemic disease.World J Gastroenterol 2008; 14(26):4111-4119.<br />
HEART and SKELETAL MUSCLE:<br />
Urbano-Márquez A, Fernández-Solà J. The effects <strong>of</strong> alcohol on skeletal and cardiac muscle. Muscle<br />
Nerve 2004; 30: 689-707.<br />
Estruch R, Fernández-Solà J, Sacanella E, Paré C, Rubin E, Urbano-Márquez A. Relationship<br />
between cardiomyopathy and liver disease in chronic alcoholism. Hepatology 1995; 22: 532-538.<br />
NEUROLOGICAL DAMAGE:<br />
Harper C, Matsumoto I. Ethanol and brain damage. Curr Opin Pharmacol. 2005;5:73–78.<br />
Chopra K, Tiwari V. Alcoholic neuropathy: possible mechanisms and future treatment possibilities. Br<br />
J Clin Pharmacol 2011 Oct 11. doi: 10.1111/j.1365-2125.2011.04111.x. [Epub ahead <strong>of</strong> print]<br />
NUTRITION:<br />
Estruch R, Sacanella E, Fernandez-Solà J, Nicolas JM. Nutritional Status in Alcoholics. In: Preedy<br />
VR Ed. The Handbook <strong>of</strong> Alcohol Related Pathology. Elseiver Science Pub, London 2005; 29: 363-<br />
377.<br />
Estruch R. Alcohol and Nutrition. In: Alcohol Misuse: an <strong>European</strong> perspective. MacDonald I (ed).<br />
Harward Acad Press; Ox<strong>for</strong>d (UK) 1996; 41-62.<br />
Sanvisens A, Rivas I, Bolao F, Tor J, Rosón B, Rey-Joly C, Muga R. Gender and liver, nutritional<br />
and metabolic alterations <strong>of</strong> severe alcoholism: a study <strong>of</strong> 480 patients. Med Clin (Barc)<br />
2011;137(2):49-54.<br />
BONE:<br />
Peris P, Parés A, Guañabens N, Pons F, Martínez de Osaba MJ, Caballería J, Rodés J, Muñoz-<br />
Gómez J.Reduced spinal and femoral bone mass and deranged bone mineral metabolism in<br />
chronic alcoholics.Alcohol Alcohol. 1992; 27(6):619-625.<br />
CLINICAL CASE : THE ACUTELY ILL PATIENT<br />
J. Altamirano,<br />
J. Caballería<br />
Barcelona, Spain<br />
E-mail: jtaltami@clinic.ub.es<br />
TOPICS: ALCOHOL WITHDRAWAL, DIAGNOSTIC AND MANAGEMENT OF ALCOHOLIC HEPATITIS,<br />
DECOMPENSATED CIRRHOSIS<br />
A 51-year-old caucasian male with arterial hypertension and no significant family history. He reported<br />
smoking 2 packs per day and drinking 8-12 beers per day <strong>for</strong> <strong>the</strong> past 20 years. One-year be<strong>for</strong>e <strong>the</strong> current<br />
presentation he started anti-depressive medication due to anxiety disorder. Over <strong>the</strong> previous 6 months,<br />
<strong>the</strong> patient had been unemployed and reported increased alcohol consumption (15-20 beers per day). He<br />
presented to <strong>the</strong> emergency room with malaise, new-on set jaundice, right abdominal pain, increment in <strong>the</strong><br />
abdominal perimeter and legs edema. At admission his vital signs were: BP 100/70 mmHg , HR 105 x`, RR<br />
22 x`, T 37.8˚C .On physical exam, <strong>the</strong> patient was noted to have conjuntival icterus, marked ascites with a<br />
prominent fluid wave and bulging flanks, bilateral pitting edema above <strong>the</strong> knees, and tender hepatomegaly.<br />
Flapping was positive on neurological examination. Significant biochemical and microbiological studies at<br />
admission are resumed in Table 1. Abdominal ultrasound revealed hepatic steatosis and no vascular or<br />
tumoral lesions were detected. Based on clinical, radiological and biochemical data diagnosis <strong>of</strong> severe<br />
alcoholic hepatitis (AH) was suspected and supportive care measures plus enteral nutrition were started.<br />
Clinical scoring systems were: Maddrey`s DF 162, MELD 33, GAHS 11 and ABIC 10.2.<br />
Initial infection screening (ascites and urine fluid analysis) was negative and blood cultures were taken.<br />
In addition, a chest-X-ray showed no pneumonia signs. He began with increased anxiety, insomnia and<br />
irritability, so clometiazol was initiated. For diagnostic confirmation a transjugular liver biopsy was per<strong>for</strong>med<br />
and 24-hrs after, histological analysis revealed: macro and micro vesicular steatosis with presence moderate<br />
PNM infiltration on portal tracts, presence <strong>of</strong> hepatocyte ballooning and Mallory-Denk bodies, occasional<br />
megamitochondria, severe hepato-canallicular and ductular cholestasis and bridging fibrosis. Prednisolone<br />
PO (40mg/day) was initiated and a mild improvement on liver function tests was documented in Day 2<br />
<strong>of</strong> hospitalization (Table 1), but 2 days later, <strong>the</strong> patient present fever (T 39˚C) with progressive dyspnea<br />
and productive cough. Blood and sputum cultures were per<strong>for</strong>med. Chest radiographs revealed left lower<br />
lobe pneumonia and IV antibiotic treatment with ceftazidime (2gr TID) plus cipr<strong>of</strong>loxacin (400mg TID) was<br />
initiated. At day 7 (Table 1) <strong>the</strong> patient’s Lille score was 0.79 and corticosteroids were interrupted.<br />
In addition, a progressive and sustained increment in serum creatinine levels and deterioration in his<br />
sodium serum levels were documented (Figure 1). Patient was expanded with IV albumin <strong>for</strong> 48 hr without<br />
renal improvement and diagnosis <strong>of</strong> hepatorenal syndrome associated with infection was established. At<br />
this time, IV terlipressin (1mg every 6 hr) and albumin treatment was initiated without any improvement<br />
on renal function. At day 10 <strong>of</strong> hospitalization <strong>the</strong> patient initiated with hemodynamic deterioration and<br />
grade 3 hepatic encephalopathy. He was <strong>the</strong>n admitted to ICU in where terlipressin was interrupted and<br />
norepinephrine was initiated. 24-hrs after ICU admission, <strong>the</strong> patient present exitus letalis.