Hepatitis Central

University of Iowa Family Practice Handbook, 3rd Edition, Chapter 4

Gastroenterology: Alcoholic Liver Disease, Liver Failure and Chronic Liver Disease

Peter P. Toth, M.D., Ph.D.
Department of Family Medicine
University of Iowa
Peer Review Status: Externally Peer Reviewed by Mosby

Alcoholic Liver Disease

1. Cause is chronic alcohol ingestion.
2. See chronic liver disease below for symptoms and signs.
3. Clinically resembles hepatitis and progresses to cirrhosis.
4. Must abstain from alcohol.
5. See chronic liver disease below for manifestations and treatment.

Liver Failure and Chronic Liver Disease

1. Cirrhosis
   Cirrhosis is a diffuse process consisting of islands of regenerated liver surrounded by dense fibrosis that occurs after a protracted insult (such as alcohol, chronic active hepatitis).
2. Symptoms of Cirrhosis
   Weight loss, malnutrition, fatigue, easy bruising (caused by reduced levels of factors II, VII, IX, and X), jaundice, encephalopathy, pruritus, edema, and ascites. The patient may also have GI bleeding from esophageal varices (caused by portal hypertension) or coma. Look for fetor hepaticus, asterixis, and hyperreflexia. GI bleeding is a common cause of encephalopathy and coma in liver failure patients because of the large gastrointestinal protein load.
3. Laboratory Evaluation
   Laboratory evaluation may show normal liver enzymes in end-stage disease because of the small amount of residual hepatic tissue. These patients will usually have low serum levels of total protein and albumin. Anemia and thrombocytopenia may also be present. Blood ammonia levels may be elevated, but these correlate poorly with clinical manifestations of coma. Electrolyte abnormalities include hyponatremia, hypokalemia, and water overload (see also sections on these topics). There may also be concomitant acidosis or alkalosis.
4. Treatment
   Consists in removal of the offending agent (such as alcohol).
   1. Acute treatment (for coma or encephalopathy).
      1. Clean bowels with enemas.
      2. Neomycin 4 to 6 g PO QD in divided doses to reduce bacterial toxins. May be given via NG tube.
      3. Lactulose 30 to 45 g PO TID to produce two or three loose stools per day.
      4. Limit total protein intake to 20 to 40 g/day.
      5. Vitamin K 5 to 10 mg/day for 2 or 3 days may help coagulation.
      6. Potassium supplements may be used for hypokalemia.
      7. Potassium-sparing diuretics such as spironolactone 100 to 300 mg/day divided into 2 or 3 doses will reduce ascites without decreasing potassium. Hydrochlorothiazide or furosemide may be added to this regimen if needed (see section on ascites below).
   2. Chronic treatment. Chronic treatment includes the prevention of coma or encephalopathy with the measures outlined above as well as chronic management of electrolyte disorders.
      1. Watch for spontaneous peritonitis, which can occur with ascites (see section on ascites).
      2. Acetaminophen toxicity is common in this population with doses that are generally considered nontoxic.

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