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Alcoholic Liver Disease (ALD)

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Definition of alcoholic liver disease (ALD)

  • A spectrum of alcohol-induced liver dysfunction ranging from mild, reversible fatty liver to irreversible liver fibrosis and cirrhosis.

 

Epidemiology of alcoholic liver disease (ALD)

  • Common – difficult to say exactly how much as many cases don’t present or are asymptomatic
  • About 20% of alcoholics will get cirrhosis
  • Risk factors:
    • Continuous high alcohol intake
    • Binge drinking (although occasional binges better than drinking a lot every day)
    • Genetic predisposition
      • 50% of heavy drinkers have normal livers
    • Women most susceptible than men

 

Video on alcoholic liver disease

 

Pathogenesis of alcoholic liver disease (ALD)

  • Possible pathogenesis includes:
    • Alcohol processing in the liver increases the NAD/NADH ratio, which causes more fatty acid synthesis and less fatty acid oxidation, causing fatty liver.
    • Acetaldehyde produced from alcohol may also damage liver cells
    • Alcohol might convert normal hepatocytes into myofibroblasts, which lay down collagen and cause fibrosis.
    • Alcohol also enhances the effects of other toxins on the liver (e.g. paracetamol).

 

Presentations of alcoholic liver disease (ALD)

 

  • Fatty liver
    • Accumulation of fat inside hepatocytes
    • Can begin to occur after only a few days of drinking heavily
    • Usually asymptomatic and with no signs
  • Alcoholic Hepatitis
    • Inflammation of hepatocytes due to excessive alcohol intake
    • Cases range from mild with only derangement of liver function tests to severe with a high mortality rate.
    • Moderate cases may have mild jaundice, hepatomegaly and signs of chronic liver disease
    • Severe cases may have decreased GCS, encephalopathy, high bilirubin levels and prolonged prothrombin times.
  • Cirrhosis

 


Pathophysiology of cirrhosis (not specifically ALD)

 

Differential diagnosis of alcoholic liver disease (ALD)

 

Diagnosis of alcoholic liver disease (ALD)

  • Fatty liver
    • Ultrasound scan can pick up fatty change in the liver
  • Alcoholic hepatitis
    • Patient with significant alcohol intake who develops deranged liver function tests; especially with an elevated bilirubin and an AST:ALT usually greater than 2.
    • The transaminases are rarely > 500

 

Initial management of alcoholic liver disease (ALD)

  • See chronic liver disease section for initial investigations and management
  • Advise to cut down and ideally STOP drinking
    • Involve local drug and alcohol liaison teams
    • Inpatient/outpatient detoxification schemes if appropriate
  • If admitted to hospital
    • Give intravenous B vitamins
      • IV Pabrinex I+II 1 vial three times daily for 3 days unless Wernicke’s is suspected in which give 2 vials three times daily for 5 days
    • Once discharged then give oral B vitamins
      • Vitamin B Compound Strong 2 tablets daily
    • Monitor for and treat withdrawal symptoms
      • Some hospitals still prescribe a reducing regime of a long-acting benzodiazepine (e.g. Chlordiazepoxide approx. 20mg QDS to for first day, decreasing daily),
      • However, others are now using a regular scoring system and giving benzodiazepines on an as-needed basis (e.g. CIWA scoring system)
    • Ensure adequate nutrition
      • Give high-calorie supplements or NG feeding if needed
    • Avoid opiates
    • Give laxatives +/- enemas to ensure bowels opening 2-3 times a day

 

Further management of alcoholic liver disease (ALD)

  • Steroids or pentoxifylline for alcoholic hepatitis
    • The use of steroids or an oral phosphodiesterase inhibitor (pentoxifylline) for patients presenting with severe alcoholic hepatitis has been controversial.
    • The STOPAH trial reported in 2014 that only steroids improved 28-day mortality but there was no difference between either drug in 1 year mortality
    • The major determinant of survival was abstinence from alcohol
  • Patients have traditionally been treated with prednisolone 40mg if they present with hepatic encephalopathy or a modified Maddrey’s discriminant function > 32
  • Sepsis is a contraindication to giving steroids

 

Complications of alcoholic liver disease (ALD)

 

Prognosis of alcoholic liver disease (ALD)

  • Mortality of severe alcoholic hepatitis is 50%

 

Click here for medical student OSCE and PACES questions about Alcoholic Liver Disease (ALD)

Common Alcoholic Liver Disease (ALD) exam questions for medical students, finals, OSCEs and MRCP PACES

 

Click here to download free teaching notes on Alcoholic Liver Disease: Alcoholic liver disease

Perfect revision for medical students, finals, OSCEs and MRCP PACES