• Clinical science

Alcoholic liver disease

Abstract

Alcoholic liver disease (ALD) refers to a range of progressive liver conditions caused by chronic and excessive alcohol consumption. One-third of the US population consumes alcohol above recommended levels, increasing their risk of ALD. There are three stages of ALD, which may or may not occur sequentially. The first stage involves the development of a potentially reversible alcoholic fatty liver, which is typically asymptomatic. Continued alcohol consumption may lead to alcoholic hepatitis, the second stage, which often becomes chronic. Clinical findings in this stage include jaundice, fatigue, and fever. In the last stage, the patient develops alcoholic cirrhosis. Patient history, transaminase levels, and imaging studies are crucial for diagnosis and show different patterns of hepatic injury. Non-alcoholic steatohepatitis is a differential diagnosis and is currently regarded as an important cause of cirrhosis. Treatment requires complete cessation of alcohol use.

Epidemiology

  • Second most common cause of liver cirrhosis in the United States
  • 28% of the US population exceeds the recommended limits of alcohol consumption.
  • Lifetime prevalence of alcohol abuse: 18%
  • ∼ 10–20% of heavy drinkers develop cirrhosis.

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Alcoholism is a very important cause of chronic liver diseases.
  • Significant alcohol consumption
    • Men: > 210 g pure alcohol per week
    • Women: > 140 g pure alcohol per week

References:[1][5]

Pathophysiology

Clinical features

The stages of ALD may overlap and do not necessarily occur in sequence.

Alcoholic fatty liver (reversible)

  • Mostly asymptomatic
  • A sensation of pressure in the upper abdominal area occurs in some patients.
  • Hepatomegaly: soft in consistency
  • Acute exacerbation with risk of hepatic failure occurs rarely.

Alcoholic hepatitis (reversible in mild cases)

  • Nonspecific symptoms: nausea, loss of appetite, weight loss, low-grade fever with tachycardia
  • Hepatomegaly; with hepatic tenderness
  • Jaundice
  • Symptoms of withdrawal in alcohol-dependent individuals
  • Splenomegaly and ascites may be present.
  • Chronic and persistent course leads to alcohol-related cirrhosis.

Hepatic fibrosis and sclerosis

Alcohol-related cirrhosis (irreversible)

  • See “Symptoms/Clinical findings” in the learning card on cirrhosis.

References:[6][7]

Diagnostics

A history of alcohol abuse that correlates with typical laboratory and imaging findings is diagnostic of alcoholic liver disease.

Alcoholic fatty liver

Imaging and laboratory studies in the case of alcoholic fatty liver will show a reversal of changes within a month if the patient abstains from alcohol!

Alcoholic hepatitis

Hepatic fibrosis and sclerosis

Alcohol-related cirrhosis

  • See cirrhosis.
  • Diagnosis confirmed by biopsy

References:[8][7][9][10][11]

Pathology

  1. Alcoholic fatty liver
    • Accumulation of lipid droplets in the hepatocytes with gradual single cell necrosis within the lobules
  2. Alcoholic hepatitis
  3. Alcohol-related cirrhosis
    • Infiltration of lymphocytes
    • Pseudolobules massive accumulation of fat in hepatocytes
    • Portal-portal and portal venous fibrous septa with increasingly cirrhotic changes

Alcoholic fatty liver and mild alcoholic hepatitis may be reversible after cessation of alcohol intake. However, severe alcoholic hepatitis and cirrhosis are not reversible!

References:[12][10][13][14][15]

Differential diagnoses

Non-alcoholic steatohepatitis (NASH)

NASH is a diagnosis of exclusion! Other causes of chronic liver disease must be ruled out by laboratory studies and/or biopsy.

A distinction between alcoholic and non-alcoholic fatty liver disease can only be drawn based on the patient history!

References:[16][17]

The differential diagnoses listed here are not exhaustive.

Treatment

References:[7]

Complications

Decompensated cirrhosis

Mainly characterized by a constellation of clinical features resulting from decreased hepatic function:

Other organ damage following chronic alcohol use

Zieve syndrome

We list the most important complications. The selection is not exhaustive.

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last updated 11/01/2018
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