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Updated: Dec 11 2021

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
    • Associated conditions
      • malnutrition
        • Wernicke encephalopathy
        • Korsakoff syndrome
      • hepatic encephalopathy
    • 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
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