Alcoholic Liver Disease

Question 1

what is the definition of ALD?

Answer 1

Alcoholic liver disease (ALD) has 3 stages of liver damage: fatty liver (steatosis), alcoholic hepatitis (inflammation and necrosis), and alcoholic liver cirrhosis. All are caused by chronic heavy alcohol ingestion

Question 2

what is the epidemiology of ALD?

Answer 2

Alcoholic liver disease accounts for 3 million deaths annually worldwide, increasing in incidence

Question 3

what is the aetiology of ALD?

Answer 3

Caused by chronic heavy alcohol ingestion. About 40 to 80 g/day in men and 20 to 40 g/day in women for 10 to 12 years is sufficient to cause liver damage in the absence of other liver diseases.

Question 4

what are the risk factors for ALD?

Answer 4

prolonged heavy alcohol consumption,
presence of hepatitis C,
female sex

Question 5

what is the pathophysiology of ALD?

Answer 5

Chronic alcohol use upregulates cytochrome P-450 2E1 and produces more free radical
Excessive NADH in relation to NAD inhibits gluconeogenesis and increases fatty acid oxidation, which in turn promotes fatty infiltration in the liver.

Question 6

what are the key presentations of ALD?

Answer 6

Right upper abdominal pain and hepatomegaly

Question 7

what are the signs of ALD?

Answer 7

Hepatomegaly

Presence of risk factors

Question 8

what are the symptoms of ALD?

Answer 8

Upper abdominal pain 
Ascites
Weight loss
Weight gain
Malnutrition
Anorexia
Fatigue

Question 9

what are the first line and gold standard investigations for ALD?

Answer 9

• measure liver damage, causation of alcohol cannot be diagnostic without history and biopsy
• AST and ALT - men: >30 units/L; women: >19 units/L, ratio >2Serum alkaline phosphate
• Serum bilirubin
• Serum albumin
• Serum gamma-GT
• FBC
• Serum electrolytes
• Serum urea and creatinine
• Serum prothrombin time
• Hepatic ultrasound

Question 10

what other tests could be considered for ALD?

Answer 10

Viral hepatitis serology
Serum iron
Urine copper

Question 11

what are the differential diagnoses of ALD?

Answer 11

Hep B, hep C, Hep A, Cholecystitis, Hepatic vein thrombosis, acute liver failure

Question 12

how is ALD managed?

Answer 12

• reduced alcohol intake
• Weight loss
• smoking cessation
• Immunizations (flu etc.)
• improved nutrition
  Medications:
• Corticosteroids
  Treat symptoms (ascites)
  Patients with end-stage ALD should be considered for liver transplantation

Question 13

how is ALD monitored?

Answer 13

ALD can be monitored through periodic liver function tests and visits to the healthcare provider. It is important to evaluate any worsening of signs and symptoms

Question 14

what are the complications of ALD?

Answer 14

• Alcohol withdrawal syndrome (treat with benzodiazepines)
• Hepatic encephalopathy, portal hypertension, GI bleeding, coagulation, renal failure, hepatorenal syndrome, hepatocellular carcinoma, sepsis

Question 15

how is alcohol withdrawal syndrome classfied?

Answer 15

-Mild AWS
Hypertension and tachycardia
Anorexia, anxiety, emotional lability, insomnia, irritability, diaphoresis, headache, and fine tremor
-Moderate AWS (worsening mild AWS, plus):
Agitation and coarse tremor
-Severe AWS/delirium tremens (worsening moderate AWS, plus):
Confusion/delirium
Generalised tonic-clonic seizures (this may be the first manifestation of AWS for some patients)
Auditory, visual, or tactile hallucinations
Hyperthermia subsequent to psychomotor agitation

Question 16

what is the prognosis for ALD?

Answer 16

short term - excellent
long term - cirrhosis likelyThe 5-year survival rate for people with cirrhosis who stop drinking is about 90%, compared with 70% of those who do not stop drinking.