Key fact: Alcohol intake of about 40-80 g per day in men and 20-40 g in women per day is sufficient to cause liver damage for 10-12 years.
Alcoholic Liver Disease
There are 3 stages of liver damage in alcoholic liver disease (ALD):
Fatty Liver (Steatosis)
Earliest stage of ALD where fat accumulates in liver cells
Alcoholic Hepatitis
Inflammation and necrosis of liver tissue
Alcoholic Cirrhosis
Irreversible scarring of liver tissue
These are caused by long-term heavy alcohol intake
Risk Factors
- Long-term heavy drinking
- Hepatitis C
- Female - ALD progresses more rapidly in women than in men and occurs when alcohol consumption is lower
Clinical Features
General Symptoms
- Right upper-quadrant discomfort or pain
- Hepatomegaly
- Variceal bleeding
- Ascites
- Weight loss or gain
- Malnutrition and wasting
- Anorexia & fatigue
Advanced Disease
- Bloating and weight gain (ascites)
- Consciousness disturbance (hepatic encephalopathy)
- Vomiting blood or black stools (bleeding from the gastrointestinal tract)
- Flapping tremor
- Lower extremity swelling
Physical Signs
- Dupuytren's contracture
- Finger clubbing
- Skin telangiectasia
Diagnosis
Medical History
A comprehensive drinking history provided by the patient and family members is critical. Questionnaires commonly used to assess the presence of alcohol dependence are:
- Alcohol use disorders identification test (AUDIT)
- AUDIT-C
- CAGE questionnaire
The CAGE questionnaire is easier to use, but the AUDIT and AUDIT-C are more reliable.
Physical Examination
Patients with advanced alcoholic liver disease can present with manifestations of portal hypertension, including:
- Ascites
- Splenomegaly
- Venous collateral circulation
Investigation
| Test |
Findings |
| LFTs |
- AST > ALT (ratio typically >2)
- Elevated GGT and ALP
- Low albumin (impaired synthesis)
- Elevated bilirubin
|
| FBC |
- Anemia (various causes)
- Macrocytosis (MCV >100)
- Thrombocytopenia
|
| Coagulation |
Prolonged PT and increased INR (decreased hepatic synthetic function) |
| Electrolytes |
- Hyponatremia
- Hypokalemia
- Hypophosphatemia
|
Other tests:
- Viral hepatitis serology (hepatitis A, B, C)
- Liver biopsy (diagnostic but not always required)
Management
The main goal of treatment is to reduce liver damage caused by alcohol overuse and prevent liver disease progression.
Alcohol Withdrawal
Abstinence or simply reducing alcohol intake can improve the expected survival of patients with ALD, and even those with decompensated cirrhosis.
Alcohol withdrawal syndrome (AWS) may occur when alcohol is withdrawn. Mild or moderate AWS can appear within 6 to 24 hours of a patient's last drink and may progress to more severe conditions.
Pharmacotherapy of Alcohol Withdrawal Syndrome
- Long-acting benzodiazepines (eg, diazepam) - better protection against seizures and delirium
- Short-acting benzodiazepines (eg, oxazepam, lorazepam) - safer for elderly and patients with liver dysfunction
Other Measures
- Lifestyle: Weight loss, smoking cessation
- Immunization: Influenza and pneumococcal vaccines recommended
- Nutrition: Enteral nutrition recommended; tube feeding if inadequate oral intake
Medical Therapy
- Consider corticosteroid (prednisolone)
- Pentoxifylline not recommended for severe alcoholic hepatitis
Ascites Treatment
- Diagnostic aspiration to rule out spontaneous bacterial peritonitis
- Sodium-restricted diet (2g sodium per day)
- Diuretics (furosemide + spironolactone) if liver function worsens
- TIPS for massive ascites
Treatment of Concomitant Hepatitis C
Antiviral therapy may improve efficacy after alcohol withdrawal, but generally not recommended during active alcohol abuse.
Terminal Disease
Liver transplantation should be considered in patients with end-stage ALD. Patients must be alcohol abstinent for at least 6 months.