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 Associated conditions malnutrition Wernicke encephalopathy Korsakoff syndrome hepatic encephalopathy ETIOLOGY Pathophysiology ethanol consumption leads to promotion of lipid accumulation within the liver liver cell injury due to increased oxidative stress decreased intake of vitamins 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