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Alcoholic Liver Disease (ALD)



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%


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


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