Updated: 12/21/2019

Alcoholic Liver Disease

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Snapshot
  • A 44-year-old man presents to the emergency department with abdominal pain. He has been experiencing this pain for the past few days, and it has progressively worsened. He has a past medical history of alcohol use disorder, complicated by previous hospital admissions for acute pancreatitis. Physical examination is notable for right upper quadrant tenderness and hepatomegaly. Laboratory studies demonstrate a serum aspartate aminotransferase level of 315 U/L and an alanine aminostransferase level of 152 U/L. 
Introduction
  • Overview
    • excessive alcohol use can lead to
      • alcoholic fatty liver disease
      • alcoholic hepatitis
      • cirrhosis
  • Pathophysiology
    • ethanol consumption leads to
      • promotion of lipid accumulation within the liver
      • liver cell injury due to increased oxidative stress
      • decreased intake of vitamins
  • Associated conditions
    • malnutrition
      • Wernicke encephalopathy
      • Korsakoff syndrome
    • hepatic encephalopathy
Presentation
  • Patients are typically asymptomatic
    • symptoms depend how severe the liver damage is and if the patient developed cirrhosis
  • Symptoms/physical exam
    • palmar erythema
    • gynecomastia
    • testicular atrophy 
    • spider angiomas
    • jaundice
    • caput medusae
    • hematemesis or melena
Imaging
  • Abdominal ultrasound
    • indication
      • to evaluate liver morphology, which may demonstrate hepatic steatosis or cirrhosis 
Studies
  • Serum labs
    • aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
      • elevated AST to ALT ratio > 2 
    • gamma-glutamyl transpeptidase (GGT)
      • often elevated
        • not specific for alcoholic liver disease
    • macrocytosis
      • suggestive of longstanding disease
      • secondary to decreased vitamin B12 or folate deficiency or alcoholic toxicity
Differential
  • Viral hepatitis
    • differentiating factors
      • significantly elevated AST and ALT
      • positive hepatitis testing
Treatment
  • Conservative
    • cessation of alcohol 
      • indication
        • all patients with alcoholic liver disease
        • associated with improved outcomes
    • nutritional therapy
      • indication
        • vitamin replacement
  • Medical
    • glucocorticoids
      • indication
        • severe alcoholic hepatitis
  • Surgical
    • liver transplantation
      • indication
        • in patients with decompensated liver disease
Complications
  • Gastroesophageal varices
    • secondary to portal hypertension
  • Hepatocellular cancer
  • Ascites
    • can result in spontaneous bacterial peritonitis

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