barcelona . spain - European Association for the Study of the Liver

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