Alcoholic Liver Disease

Question 1

Alcoholic liver disease

Answer 1

Chronic and excessive alcohol consumption is one of the major causes of liver disease

Question 2

Hepatic disease process in alcoholic liver disease

Answer 2

1. Alcoholic fatty liver disease
2. Alcoholic hepatitis
3. Cirrhosis

Question 3

What is the most common manifestation of alcoholic liver disease

Answer 3

Fatty liver disease

Question 4

What are the most important risk factors for development of alcoholic liver disease?

Answer 4

Quantity and duration of alcohol intake

Question 5

______ are more susceptible to liver disease with less alcohol intake

Answer 5

women

Question 6

Threshold for developing alcoholic liver disease

Answer 6

Men: >60-80 g/d ETOH x 10 yrs

Women: >20-40 g/d ETOH x 10 yrs

Ingestion of 160 g/d is associated with a 25 fold increased risk of developing alcoholic cirrhosis

Question 7

Alcoholic liver disease and chronic HCV infection

Answer 7

Chronic HCV infection is an important comorbidity

Even moderate ETOH in pt with HCV increases risk of cirrhosis and hepatocellular carcinoma

HCV and alcoholic liver disease has poorer overall survival rate

Question 8

Fatty liver disease

Answer 8

Typically first sign of liver disease in patients who consume alcohol.

Microscopically, it looks like fat droplets within the cytosol of hepatocytes

Question 9

Fatty liver: Sreatohepatitis

Answer 9

Inflammation as well as presence of fat cells in the liver.

Question 10

Fatty liver: mallor bodies

Answer 10

aka Mallory’s hyaline

intracellular inclusion body) on biopsy.

Question 11

Pts with steatohepatitis from alcohol are typically ______

Answer 11

Asymptomatic

Question 12

Alcoholic liver disease: Labs

Answer 12

AST to ALT ration 2:1
Increased GGT

Could also check CBC for anemia and platelets

Question 13

Alcoholic hepatitis

Answer 13

While asymptomatic steatohepatitis due to alcohol could be referred to as “alcoholic hepatitis” the term is typically used to describe the acute onset of symptomatic hepatitis.

It is the acute onset of liver hepatitis but with alcohol being the main etiology.

Characterized by liver degeneration, spotty necrosis and fibrosis

Thought to be a precursor to cirrhosis but is still potentially reversible if they stop drinking.

Question 14

Alcoholic hepatitis clinical presentation

Answer 14

Patients are typically between 40 - 50 yo with h/o heavy ETOH use (>100g/d) for > 20 years (Can also develop with h/o much shorter heavy use)

Pts often stop drinking as they become ill

Clinically acute hepatitis looks like jaundice, anorexia, fever, tender hepatomegaly/ RUQ/ epigastric pain

Question 15

Alcoholic hepatitis labs

Answer 15

CBC, AST, ALT, GGT, bilirubin, albumin, PT

Rule out other causes of acute hepatitis – Anti HAV IgM, HBsAg, anti HBV core IgM, anti HCV, HCV RNA

Question 16

Alcoholic hepatitis lab results

Answer 16

Moderate elevations of the AST and ALT (typically less than 300 int. unit/L, rarely higher than 500 int. unit/L)

AST: ALT ratio > 2
Elevated serum bilirubin
Elevated GGT
Leukocytosis with a predominance of neutrophils
Elevated INR/PT

Question 17

Alcoholic hepatitis diagnosis

Answer 17

Dx made based on clinical and lab features in context of long history of heavy ETOH use.

Need to look for other associated conditions due to ETOH including cardiomyopathy, skeletal muscle wasting, pancreatic dysfunction, and neurotoxicity

Question 18

Alcoholic hepatitis treatment

Answer 18

If severe, hospitalization
Abstinence from alcohol!
Can rapidly progress to hepatic failure and death.

Nutritional support
Fluid management/hydration
Use of corticosteroids is controversial but used in severe cases
pentoxifylline [Trental] inhibits tumor necrosis factor (TNF) synthesis, which is increased in patients with alcoholic hepatitis (has anti-inflammatory properties; used in severe cases)

Liver transplant in patients with advanced liver disease from alcohol (6 month abstinence and rehab program)

Question 19

Nonalcoholic fatty liver disease (NAFLD)

Answer 19

A disorder that encompasses several disorders: 
simple steatosis
steatohepatitis
fibrosis, and 
end stage liver disease (ESLD) 
in the absence of alcohol consumption

Question 20

Nonalcoholic fatty liver disease (NAFLD) risk factors

Answer 20

Female, insulin resistance, type II diabetes, central obesity, hypertension, dyslipidemia

Question 21

Nonalcoholic fatty liver disease (NAFLD) risk factors

Answer 21

From asymptomatic to advanced disease and HCC

Question 22

NAFDL history

Answer 22

significant ETOH (>2 drinks/day in men and >1 drink/day in women) must be ruled out
review of meds, OTC meds, herbals, & supplement

Question 23

NAFDL diagnosis

Answer 23

Confirmatory imaging (US)

Liver biopsy is gold standard of diagnosis: looking histologically for macrosteatosis, hepatocyte ballooning, mixed lobular inflammation

Labs: Liver enzyme elevations are usually mild and up to 80% of pts have normal liver enzymes.

Question 24

NAFDL treatment: Pharmacologic

Answer 24

These improve liver histology and function: Vitamin E, statins, metformin, TZDs (thiazolidinediones)
Correction of associated conditions (e.g., hyperlipidemia, diabetes; discontinue any hepatotoxins)

Question 25

NAFDL treatment: Nonpharmacologic

Answer 25

Weight loss and exercies

Liver transplant for advanced cirrhosis

Question 26

NAFDL prevention (prevent further damage)

Answer 26

Hep vaccines and other age appropriate immunizations
Avoid ETOH
Manage cardiovascular risk factors (see above)

Question 27

NASH monitoring

Answer 27

NASH is associated with increased risk of HCC

Annual screening with abdominal imaging and alpha fetoprotein (AFP)

Question 28

Nonalcoholic steatohepatitis (NASH)

Answer 28

Part of the spectrum of NAFLD and consists of: 
steatosis
hepatocellular ballooning
lobular inflammation, and 
fibrosis 
Risk of progression to cirrhosis
Makes up ~1/5 of NAFLD