Internal Medicine

P1: SBT

0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18

Alcoholic Liver Disease (ALD) 91

■Hereditary hemochromatosis

■Acetaminophen toxicity w/ alcohol consumption

management

What to Do First

■Establish diagnosis & assess severity of liver disease, rule out infec-

tion

■Determine risk of alcohol withdrawal

■Delirium tremens: temperature, tremor, tachycardia

General Measures

■Adjust or avoid potentially hepatotoxic medications

■Correct electrolyte abnormality & dehydration

■Correct nutritional deficiencies

■Thiamine, folate, pyridoxine, vitamin K (if PT prolonged)

■Benzodiazepines for acute alcohol withdrawal

■Diagnostic paracentesis in pts w/ ascites & abdominal pain

specific therapy

■Corticosteroids for selected pts w/ severe alcoholic hepatitis:

➣Prednisolone or methylprednisolone for 4 wk followed by taper

& discontinuation over 2–4 wk

➣Indications: severe alcoholic hepatitis w/ discriminant function

[4.6×(PT in seconds minus control)+bilirubin in mg/dL] >32

&/or hepatic encephalopathy

➣Contraindications:

Absolute: mild alcoholic hepatitis w/ discriminant function

<32 & absence of hepatic encephalopathy

Relative: corticosteroid use either dangerous or benefit not

proven in pts w/ active infection, renal failure, pancreatitis,

active GI bleeding

■Liver transplantation:

➣Indication: cirrhosis w/ Child-Turcotte-Pugh score 7 or more, or

evidence of decompensation, & minimum of 6 mo of sobriety

➣Contraindication: active alcohol use or other contraindication

for liver transplant

■Nutritional supplementation:

➣Enteric feeding before PPN or TPN; multivitamins & minerals

➣Indication: protein calorie malnutrition &/or to maintain posi-

tive nitrogen balance

➣Side effects & contraindications: severe hepatic encephalopathy