- Clinical science
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 the recommended levels, increasing their risk of ALD. There are three stages of ALD, which may or may not occur sequentially. The first stage is typically asymptomatic and involves the development of (potentially) reversible alcoholic fatty liver. 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 third and final stage, the patient develops alcoholic cirrhosis. Patient history, transaminase levels, and imaging studies are crucial for diagnosis and show different patterns of hepatic injury. Nonalcoholic steatohepatitis is a differential diagnosis and is currently regarded as an important cause of cirrhosis. Treatment of ALD requires complete cessation of alcohol use.
- 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.
Epidemiological data refers to the US, unless otherwise specified.
- 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
- Hepatic degradation of ethanol to acetyl-CoA by alcohol dehydrogenase results in NADH excess (see breakdown of ethanol for more details) → ↑ NADH drives the formation of glycerol 3-phosphate (G3P) from dihydroxyacetone phosphate (DHAP) → ↑ in both G3P and fatty acids causes increased triglyceride synthesis in the liver → steatohepatitis
The stages of ALD may overlap and do not necessarily occur in sequence.
Alcoholic fatty liver (reversible)
- Mostly asymptomatic
- Some patients report feeling a sensation of pressure in the upper abdominal area.
- Hepatomegaly: soft in consistency
- Regresses after cessation of alcohol consumption
Alcoholic hepatitis (reversible in mild cases)
- Develops as a result of persistent, long-term alcohol use
- Nonspecific symptoms: nausea, loss of appetite, weight loss, low-grade fever with tachycardia
- Hepatomegaly; with hepatic tenderness
- Symptoms of withdrawal in alcohol-dependent individuals
- Splenomegaly and ascites may be present.
- Final stage of ALD
- See “Clinical features” in .
- AST (aspartate aminotransferase) > ALT (alanine aminotransferase) (both ↑ ALT and ↑ AST)
- ↑ GGT
- ↑ Serum ferritin
- Macrocytic anemia
↑ CDT(carbohydrate-deficient transferrin)
- Most specific biomarker of heavy alcohol use regardless of the presence of liver disease
- Levels elevated up to 6 weeks after abuse
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!
- Laboratory tests
- See .
- Diagnosis confirmed by biopsy
- Alcoholic fatty liver
- Fatty liver with hydropic swelling and ballooning degeneration of hepatocytes within the lobules
- Damaged hepatocytes typically contain Mallory bodies (hyaline inclusion bodies that contain keratin filaments and appear eosinophilic on H&E stain)
- Immunoreaction: Neutrophilic granulocytes infiltrate hepatic tissue.
- Fibrosis: pronounced excess formation of fibrous collagenous connective tissue in perivenous zones
- Alcohol-related cirrhosis
- Definition: non-alcohol related accumulation of fat in the liver cells with risk of inflammation and cirrhosis
- Very widespread
- Clinical presentation
- Weight loss, optimization of diabetic treatment
- Discontinue responsible medication
- Complications: cirrhosis, hepatocellular carcinoma
A distinction between alcoholic and non-alcoholic fatty liver disease can only be drawn based on patient history!
The differential diagnoses listed here are not exhaustive.
Mainly characterized by a constellation of clinical features resulting from decreased hepatic function:
Other organ damage following chronic alcohol use
- Acute hemolytic anemia after excessive alcohol use over the course of several years, characterized by the following triad:
We list the most important complications. The selection is not exhaustive.