Diagnosis

Alcoholic liver disease

Etiology

Pathophysiology

The precise mechanism of alcoholic liver disease remains in dispute: [kfz]

• Metabolism of alcohol through alcohol dehydrogenase --> acetaldehyde --> acetate

• Acetaldehyde is a reactive metabolite that can produce injury:

  • Genetic factors

  • Protein-energy malnutrition

  • Toxic effects on hepatocyte cell membranes and mitochondrial membranes

  • Hypermetabolic state of the hepatocyte --> hypoxic damage

  • Free radicals and oxidative injury

  • Steatosis (accumulation of fat in the hepatocytes)

  • Autoimmune factors

The relative risk of cirrhosis rises significantly for alcohol intake above 60 g/day for men and 20 g/day for women over a decade [dfu][9oc][dir]. 1 beverage = 14 grams of alcohol. With continued heavy alcohol consumption, the alcoholic liver disease progress from fatty liver (steatosis) --> hepatitis --> cirrhosis. [nd8]

1. Alcoholic Fatty Liver (steatosis):

   • ~20% of alcoholics and heavy drinkers

   • Usually no clinical symptoms except for hepatomegaly

   • Fatty liver can be reversed if alcohol consumption is stopped

2. Alcoholic Hepatitis

   • Liver biopsy indicates inflammatory changes, liver degeneration, fibrosis

   • Clinical signs: hepatomegaly, nausea, vomiting, abdominal pain, fever, jaundice

   • If heavy drinking continues, ~40% of cases of alcoholic hepatitis --> cirrhosis

3. Alcoholic Cirrhosis

   • ~10-15% with alcoholism develop cirrhosis

   • The most serious form of ALD

   • Scar tissue replaces normal liver tissue, disrupting blood flow through the liver and preventing it from working properly

   • Clinical signs: palmar erythema, finger contractures, white nails, nails clubbing, hepatomegaly, inflammation, steatosis, jaundice, ascites, or gastrointestinal bleeding

   • The survival rate is only 60 percent for those who stop drinking and 35 percent for those who do not

Epidemiology

Incidence per 100.000 [dir][ton][dsy][yno][d79][ays][ofq][nd8]

Approach

• Blood test: ASAT, ALAT, ALP, GGT, PT-INR, Bilirubin, ferritin, transferrin, CRP, AFP, carbohydrate-deficient transferrin

• Viral antigens

• Ultrasound

• Liver biopsy (percutaneous or transjugular)

• Upper endoscopy to screen for esophageal varices

• Model for end-stage liver disease (MELD) score is useful in predicting the 30- and 90-day mortality in patients with alcoholic hepatitis

Treatment

1. Alcohol abstinence is the single most important determinant of long-term patient survival

2. Treatment of complications: [kfz]

   • Nutritional supplementation: vitamins and minerals, including folate and thiamine

   • Variceal hemorrhage: Protection of the airway, resuscitation, interventional endoscopy (sclerotherapy or banding ligation), infusion of portal antihypertensive (somatostatin), balloon tamponade, transjugular intrahepatic portosystemic shunt, or an emergency portal-caval shunt

   • Hepatic encephalopathy: Lactulose or nonabsorbable antibiotics, ammonium, intracranial pressure monitoring

   • Ascites: Salt restriction, diuretics, paracentesis, and intravenous albumin supplementation

   • Spontaneous bacterial peritonitis: diagnostic paracentesis --> broad-spectrum antibiotic therapy (cephalosporin)

   • Alcoholic hepatitis: Corticosteroid (prednisolone 40 mg/d) is recommended as the first-line treatment of severe AH patients

   • Cirrhosis: Liver transplantation (required a minimum 6-month abstinence)

Differential diagnoses

Autoimmune hepatitis, Chronic pancreatitis, Drug-induced liver injury, Hemochromatosis, Nonalcoholic fatty liver disease, Viral hepatitis