alcoholic liver disease in the elderly
Introduction
Introduction to alcoholic liver disease in the elderly Long-term excessive drinking, through the ethanol itself and its derivative acetaldehyde, can cause hepatic cells to repeatedly undergo fatty degeneration, necrosis and regeneration, leading to alcoholic liver disease (alcoholichepaticdisease), including alcoholic fatty liver (alcoholic fattyliver), alcoholic hepatitis ( Alcoholichepatitis, hepatic fibrosis and hepatocirrhosis, alcoholic liver disease is one of the leading causes of death among young and middle-aged people in Europe and the United States. Its clinical manifestations are diverse. It usually shows fatty liver in the early stage, and then it can develop into alcoholic hepatitis, alcoholic fibrosis and alcoholic cirrhosis. Severe alcoholism can induce extensive hepatocyte necrosis or even liver failure. basic knowledge Proportion of the disease: the probability of illness in the elderly is 0.01% Susceptible people: the elderly Mode of infection: non-infectious Complications: alcoholic cirrhosis, hepatic encephalopathy, upper gastrointestinal bleeding
Cause
The cause of alcoholic liver disease in the elderly
Related to drinking (40%):
The length of alcoholic liver disease and alcohol consumption, the amount of which is related to the variety of wine. Generally, the daily drinking amount is >40g, which can cause liver damage for 5 consecutive years. A large amount of drinking is more than 20 years, 40% to 50% will have cirrhosis, and the formula for converting ethanol is: ethanol (g) = alcoholic beverage (ml) × Ethanol content (%) × 0.8 (specific gravity of ethanol), normal humans can metabolize ethanol 120g in 24h, long-term drinking exceeds the body's metabolic capacity, can cause alcoholic liver disease, the occurrence of alcoholic liver disease is mainly the toxicity of ethanol and acetaldehyde As a result, acetaldehyde is a highly active compound that can interfere with various functions of liver cells, such as affecting mitochondria to produce ATP, protein biosynthesis and excretion, damage microtubules, and cause protein and fat excretion disorders in liver cells. Accumulation, at the same time, when ethanol and acetaldehyde are oxidized, a large amount of reduced coenzyme I is produced, which not only promotes the synthesis of fat, but also inhibits the oxidation of fatty acids in mitochondria, leading to the formation of fatty liver and hyperlacticity caused by ethanol. By stimulating the activity of proline hydroxylase to inhibit the oxidation of proline, the proline is increased, thereby increasing the formation of collagen in the liver and accelerating the cirrhosis process. Immune responses and cytokines involved in the pathogenesis of alcoholic liver disease.
1 Acetaldehyde binds to many liver proteins or enzymes, inducing the formation of antibodies that bind to the cell membrane.
2 Hepatocytes, endothelial cells, Kupffer cells and Ito cells have type I HLA expression on the surface of the membrane, and are susceptible to attack by cytotoxic T cells (Tc).
3 Alcoholic liver disease patients have deposition of IgA.
4 Many cytokines (IL-1, IL-6, TNF-, TGF-) are involved in inflammation, regeneration and fibrogenesis, such as TGF-, IL-1 stimulates Ito cells and fibroblast proliferation and fibroplasia.
Other factors (20%):
There are genetic variations in aldehyde metabolism, such as alcohol dehydrogenase, cytochrome P450 2E1 and aldehyde dehydrogenase polymorphism, sex (same conditions, women are more susceptible to morbidity than men), diet and nutrition also affect alcohol The occurrence of liver disease.
Large foaming fat infiltration (10%):
Alcoholic fatty liver can be seen in some or all of the liver cells with large foamy infiltration, vacuolization, nuclear eccentricity, occasionally bile duct in the bile duct, rarely accompanied by inflammatory response, pathological changes in alcoholic hepatitis Hepatocyte ballooning, necrosis, steatosis, alcoholic transparent body (Mallory body), etc., as well as inflammatory cell infiltration, fibrosis, alcoholic cirrhosis, generally small nodular, often fibrotic and false The formation of lobules may also have fatty liver and some changes in alcoholic hepatitis.
Prevention
Alcoholic liver disease prevention in the elderly
Primary prevention
Not drinking alcohol-containing beverages is fundamental to preventing alcoholic liver disease. In real life, it is impossible to do this completely. Therefore, the second best thing is to ask for as little drink as possible. After drinking alcohol, supplement the high-protein and high-vitamin diet and take hangover drugs such as Pueraria.
2. Secondary prevention
For patients with heavy drinking and/or long-term drinking, liver function should be checked regularly, liver biopsy should be performed if necessary, alcoholic liver disease should be detected early, and the degree of development should be determined. There is currently no specific and sensitive indicator for the diagnosis of alcoholic liver disease, which needs further study. Early treatment of alcoholic liver disease includes:
(1) Lifetime alcohol ban.
(2) high protein and high vitamin diet, especially vitamin B, vitamin A, C, K, etc., should be given a lot of folic acid.
(3) It has been reported that adrenocortical hormone is effective for fatty liver and active alcoholic hepatitis, but there are reports that the effect is not certain.
(4) The propylthiouracil has been tried and the effect cannot be determined.
Complication
Elderly patients with alcoholic liver disease complications Complications alcoholic cirrhosis hepatic encephalopathy upper gastrointestinal bleeding
Alcoholic cirrhosis, esophageal varices, liver failure, hepatic encephalopathy, upper gastrointestinal bleeding.
Alcoholic hepatitis is often due to the recent concentration of heavy drinking, loss of appetite, nausea and vomiting, and even fever and jaundice, swelling and tenderness of the liver, as well as splenomegaly, ascites, edema and spider mites. Laboratory examination of common anemia and leukocytosis, alanine aminotransferase, aspartate aminotransferase, r-glutamyl transpeptidase and serum phosphatase increased. Prone to a variety of complications:
1 The condition of liver failure deteriorates sharply after the onset of liver failure. The clinical manifestations are similar to those of severe hepatitis, often accompanied by hepatic coma, upper gastrointestinal bleeding, renal failure and secondary infection.
2 intrahepatic cholestasis jaundice is darker in color, liver is obviously swollen, abdominal pain is fever, bilirubin and serum phosphatase are significantly increased, and aspartate aminotransferase is light or moderately elevated.
3 alcoholism hyperlipidemia hemolysis syndrome is jaundice, hyperlipidemia and hemolytic anemia. As a subtype of alcoholic hepatitis, symptoms can disappear after stopping drinking.
4 alcoholic hypoglycemia, a large number of alcoholic hypoglycemia, the patient's performance is palpitations, sweating, loss of consciousness, etc., can be alleviated after injection of glucose. Alcoholic hepatitis is a category of traditional Chinese medicine "Huangqi", "hypochondriac pain", "vomiting", "accumulation" and so on. Its etiology and pathogenesis is excessive wine, damage to the spleen and stomach, wet turbidity, stagnation and heat, fumigation of liver and gallbladder, bile does not follow the usual path, soaking skin and yellowing. You should stop drinking immediately and combine Chinese and Western medicine. Clinically, it can be used in traditional Chinese medicine such as Bupleurum, Astragalus, Pinellia, Poria, Chenpi, Codonopsis, Yinchen, Hawthorn, Rhubarb, etc., soothing liver and gallbladder, clearing away heat and removing yellow, combined with Yinzhihuang injection, Xingnaojing injection, Intravenous drip of Qingkailing injection can obtain better curative effect.
Alcoholic liver fibrosis is similar to alcoholic hepatitis and often requires liver puncture for diagnosis. Its etiology and pathogenesis is long-lasting wine, phlegm and dampness, hindering in the middle coke, poor air movement, blocked venous, poor blood flow, qi stagnation and blood stasis, gas, blood and phlegm in the abdomen . Should immediately stop drinking, and take Chinese medicine Bupleurum, Astragalus, Salvia, Pinellia, scorpion, armor, etc., soothes the liver and spleen, promote blood circulation, to anti-fibrosis, or turn to cirrhosis, poor prognosis.
Symptom
Symptoms of alcoholic liver disease in the elderly Common symptoms Loss of fatigue, fatigue, nausea, loss of appetite, liver, palm, ascites, spider, abdominal pain, splenomegaly
Alcoholic fatty liver is often asymptomatic or only mildly discomfort. Generally, there may be discomfort in the liver area, fatigue, etc. The liver is large, the texture is soft, and there is tenderness. Alcoholic hepatitis usually has loss of appetite, fatigue, nausea, vomiting, weight loss, etc. , liver, splenomegaly, tenderness in the liver area, severe cases may have ascites, hepatic encephalopathy, etc. Alcoholic cirrhosis and viral cirrhosis are similar, generally have clinical manifestations of liver dysfunction and portal hypertension, spider mites Liver palm, men's breast development is quite common, ascites, esophageal varices, liver failure and so on.
Examine
Examination of alcoholic liver disease in the elderly
Serum bilirubin and AST and ALT are slightly elevated in alcoholic fatty liver and alcoholic cirrhosis, but are significantly elevated in alcoholic hepatitis. AST/ALT ratio is often greater than 1, -GT, AKP is also obvious. Elevated, more obvious with -GT, while serum hyaluronic acid, type III procollagen peptide (PIIIP), fibronectin, laminin increased significantly with the degree of fibrosis, others such as serum IgA, uric acid, Lactate, triacylglycerol, etc., blood sugar and blood magnesium decreased.
Ultrasound imaging of alcoholic fatty liver showed diffuse fine echoes of liver parenchyma and decreased echo of deep liver tissue.
Diagnosis
Diagnosis and identification of alcoholic liver disease in the elderly
Diagnostic criteria
According to the history of drinking, clinical performance and laboratory tests are not difficult to make a diagnosis. If necessary, a liver biopsy is feasible.
In the clinical diagnosis of alcoholic liver disease, the clinical classification is:
1. Light (subclinical) alcoholic liver disease
There is a long history of drinking, but the liver function test is basically normal, the liver histology is non-specific or basic, lacking ethanol transparent body and neutrophil infiltration.
2. Alcoholic fatty liver
The lesions were mainly in the hepatic lobules, and more than 1/3 of the hepatic cells in the hepatic lobules under low magnification had steatosis, no other histological changes, no liver biopsy, and imaging examination (CT or B-ultrasound) had fatty liver-specific manifestations. .
3. Alcoholic hepatitis
If no liver biopsy is performed, the clinical diagnosis should meet the following diagnostic criteria and 3 or more of the additional items. Diagnostic criteria:
1 increased alcohol consumption can be used as a cause of morbidity or deterioration;
2 AST-based serum transaminase elevation;
3 serum bilirubin increased (> 34.2 mol / L), additional items:
1 abdominal pain;
2 fever;
3 peripheral blood leukocytes increased;
4ALT>1.5 upper limit of normal value;
5-GT increased by >2 times the upper limit of normal value.
4. Alcoholic severe hepatitis (liver failure)
The clinical manifestations of liver failure such as alcoholic hepatic encephalopathy, or severe endotoxemia, acute renal failure and gastrointestinal bleeding, although the alcohol is banned, the liver continues to enlarge, prothrombin activity <40%, white blood cells Significantly elevated, histology can be seen in most ethanol transparent bodies and severe hepatocyte degeneration and necrosis, this type includes patients with cirrhosis, except for advanced cirrhosis.
5. Alcoholic liver fibrosis and/or cirrhosis
According to clinical and laboratory tests, it is difficult to diagnose alcoholic liver fibrosis. In the absence of liver biopsy, clinical imaging findings such as hyaluronic acid, PIIIP, fibronectin, and type IV collagen should be combined. When diagnosing cirrhosis, it should be classified as compensatory or decompensated.
Differential diagnosis
Should pay attention to non-alcoholic steatohepatitis, viral hepatitis (both if both exist, the symptoms are more serious), other causes of cirrhosis, etc., hepatic encephalopathy should be differentiated from alcoholic sputum.
