Alcoholic Liver Disease

Topic Highlights

●  Alcoholic Liver Disease (ALD) is also known as Alcoholic Hepatitis. 

●  It is an acute or chronic inflammation of the liver caused by excessive intake of alcohol. 

●  This presentation discusses the three stages of liver damage. 

●  The presentation also focuses on the symptoms, complications, diagnostic tests and management of the disease. 

Transcript

Alcoholic liver disease is a condition in which there is acute or chronic inflammation of the liver due to excessive intake of alcohol. The damage to the liver progresses through three stages: namely fatty liver, alcoholic hepatitis (the in-between stage) and cirrhosis.

Fatty liver is a reversible stage and usually does not lead to any chronic liver disease if the person abstains from alcohol or if moderation is maintained. Alcoholic hepatitis is a combination of fatty liver along with widespread liver inflammation and focal areas of liver necrosis. The prognosis is variable and it may lead to chronic liver disease, although the condition is sometimes reversible.

Cirrhosis is an advanced form of liver disease with extensive fibrosis with varied amounts of fat. Hepatitis may also be present. The prognosis is usually poor and the condition is generally irreversible. It usually results in conditions such as portal hypertension and liver failure.

The development of alcoholic liver disease is governed by various factors and includes genetic factors, gender (women are more susceptible to developing liver disease) and environmental factors (social acceptance of drinking, availability of alcohol, socio-economic status of the individuals, etc.). The risk of developing the disease increases with the quantity of alcohol consumed and the duration (usually more than an 8 year period). Malnutrition is also a contributory factor to the disease.

Fatty liver commonly occurs among heavy drinkers; while it can be found in up to 40% of moderate drinkers. Fatty liver can be associated with other conditions such as obesity, hyperlipidemia, insulin resistance, due to medications, etc. A careful history is necessary to rule out other causes of the condition. Not all heavy drinkers progress to alcoholic hepatitis and cirrhosis. The exact cause as to why some develop these conditions while others do not is not clear.

Patients with fatty liver usually do not have any specific signs and symptoms indicative of an acute liver condition. On physical examination, the liver is enlarged and smooth. In rare cases, there may be some tenderness.

Alcoholic hepatitis may present with a varied range of signs and symptoms depending on the stage of disease. Symptoms may include anorexia (loss of appetite), weight loss, nausea, vomiting, abdominal tenderness and distension, and fever. Some severe symptoms include liver failure and hepatic encephalopathy (confusion, decreased level of consciousness, cognition, etc.).

On examination, the findings may include hepatomegaly (enlarged liver), ascites (fluid collection in abdomen), jaundice (yellowishness of skin and eye), tachycardia (rapid heart rate), spider angiomas (reduced coagulation factors causing microhemorrhages just below the skin surface that resembles a spider's web) and findings of encephalopathy.

Cirrhosis may or may not present with a preceding history of fatty liver or of alcoholic hepatitis. The signs and symptoms are similar to other forms of cirrhosis and are usually the same as alcoholic hepatitis and end-stage liver disease. Findings include portal hypertension (high blood pressure in the portal vein) with esophageal varices (dilation of veins in the esophagus), upper gastro-intestinal bleeding, ascites, hepatic encephalopathy, hepatorenal syndrome (kidney failure due to cirrhosis, etc.)

Usually, people with a history of alcohol abuse will not be very forthcoming with information regarding their use of alcohol. Also, there are no lab tests or physical findings that are very indicative or specific of alcoholic liver disease. A diagnosis is made by taking a detailed medical history, and studying signs and symptoms, and physical findings and laboratory tests.

The laboratory tests that are generally performed include complete blood count (CBC), liver function tests (LFT) such as checking aminotransferase levels, and possibly performing a liver biopsy. Liver biopsy is performed to confirm the disease, identify the severity of the disease and intensity of injury caused due to excessive alcohol intake. Ultrasound scans of the abdomen and CT scans are also performed to rule out other causes of liver disease.

The important aspect of management is to achieve the state of abstinence from alcohol to prevent further abuse of the damaged liver. This, however, is easier said than done and usually requires the patient to be referred to a competent rehabilitation program and requires the aid of support groups such as Alcoholics Anonymous to help the patient remain motivated to quit the use of alcohol.

General management requires correction of malnutrition with vitamin supplements and a nutritious diet, especially in the first few days of abstinence. Protein supplements are also given to bring about a positive nitrogen balance. In case of encephalopathy, where protein supplements cannot be administered liberally, branched chain amino acids are given as substitute to proteins to bring about a positive nitrogen balance.

Management of the other complications such as infections, bleeding, ascites, encephalopathy, and electrolyte abnormalities are required. There are very few specific treatments for alcoholic liver disease. The use of corticosteroids in patients with alcoholic hepatitis has derived mixed opinions, although they appear to be beneficial in patients with severe forms of the disease. Various other drugs such as colchicines, penicillamine, pentoxifylline, propylthiouracil, infliximab, antioxidants, etc. have been tried out with mixed results, although success has been very limited.

In cases of advanced cirrhosis with symptoms such as ascites, peritonitis, encephalopathy, variceal bleeding, etc., liver transplants are to be considered. Liver transplants can bring about five-year survival rates comparable with those for non-alcoholic liver disease. It is essential to have a prior six months of abstinence before the transplant is performed.

The prognosis or the outcome of alcoholic liver disease is dependent on the degree of fibrosis of the liver and the inflammation present. In cases of fatty liver and hepatitis without the presence of fibrosis, with abstinence complete resolution of fatty liver can be seen in a period of around one to one-and-half months. Fibrosis and cirrhosis is around 50% and increases if the patient continues to consume alcohol and decreases if he/she refrains from alcohol intake. Hence, prognosis is not only dependent on the stage of liver disease but is also dependent on the supportive therapy and abstinence from alcohol which helps in preventing further damage of the already damaged liver.