Alcohol Liver Disease

Question 1

What is the process of progression of alcholic liver disease?

Answer 1

Alcoholic liver disease results from the effects of the long term excessive consumption of alcohol on the liver. The onset and progression of alcoholic liver disease varies between people, suggesting that there may be a genetic predisposition to having harmful effects of alcohol on the liver.

There is a stepwise process of progression of alcoholic liver disease:

1. Alcohol related fatty liver

= Drinking leads to a build-up of fat in the liver. If drinking stops this process reverses in around 2 weeks.

2. Alcoholic hepatitis

= Drinking alcohol over a long period causes inflammation in the liver sites. Binge drinking is associated with the same effect. Mild alcoholic hepatitis is usually reversible with permanent abstinence.

3. Cirrhosis

= This is where the liver is made up of scar tissue rather than healthy liver tissue. This is irreversible. Stopping drinking can prevent further damage. Continued drinking has a very poor prognosis.

Question 2

Recommended alcohol consumption

Answer 2

That latest recommendations (Department of Health, 2016) are to not regularly drink more than 14 units per week for both men and women.

If drinking 14 units in a week, this should be spread evenly over 3 or more days and not more than 5 units in a day.

Pregnant women should avoid alcohol completely.

Question 3

Examination findings associated with alcoholic liver disease

Answer 3

Jaundice
Hepatomegaly (fatty liver disease)
Spider Naevi
Palmar Erythema
Gynaecomastia
Bruising – due to abnormal clotting
Ascites
Caput Medusae – engorged superficial epigastric veins
Asterixis – “flapping tremor” in decompensated liver disease

Question 4

Investigation - Bloods

Answer 4

FBC – raised MCV

LFTs – elevated ALT and AST (transaminases) and particularly raised gamma-GT.
ALP will be elevated later in the disease.
Low albumin due to reduced “synthetic function” of the liver.
Elevated bilirubin in cirrhosis.

Clotting – elevated prothrombin time due to reduced “synthetic function” of the liver

U+Es may be deranged in hepatorenal syndrome (Complication of liver cirrhosis)

Question 5

Other investigations to do in alcoholic liver disease

Answer 5

Ultrasound
- may show fatty changes early on described as “increased echogenicity”. It can also demonstrate changes related to cirrhosis if present.

• “FibroScan” can be used to check the elasticity of the liver by sending high frequency sound waves into the liver. It helps assess the degree of cirrhosis.

Endoscopy
- assess for and treat oesophageal varices when portal hypertension is suspected

CT and MRI scans
- look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites.

Liver Biopsy
- confirm the diagnosis of alcohol related hepatitis or cirrhosis

Question 6

Alcoholic liver disease management

Answer 6

Stop drinking alcohol permanently

Consider a detoxication regime

Nutritional support with vitamins (particularly thiamine) and a high protein diet

Steroids improve short term outcomes (over 1 month) in severe alcoholic hepatitis but infection and GI bleeding need to be treated first and do not improve outcomes over the long term

Treat complications of cirrhosis (portal hypertension, varices, ascites and hepatic encephalopathy)

Referral for liver transplant in severe disease however they must abstain from alcohol for 3 months prior to referral