Updated: 10/28/2019

Alcoholic Liver Disease

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Snapshot
  • A 55-year-old man presents to his primary care physician for an annual examination. He currently does not have any acute complains; however, he continues drinking multiple alcoholic beverages daily. He noticed when he tries to stop drinking alcohol, he becomes tremulous and feels anxious. Laboratory studies demonstrate a transaminitis. An abdominal ultrasound demonstrates hepatic steatosis.
Introduction
  • Overview
    • excessive alcohol use can lead to
      • alcoholic fatty liver disease  
      • alcoholic hepatitis
      • cirrhosis
  • Pathophysiology
    • ethanol consumption leads to 
      • promotion of lipid accumulation within the liver
      • liver cell injury due to increased oxidative stress
      • decreased intake of vitamins
    • ethanol metabolism leads to the production of
      • acetaldehyde
      • reduced nicotinamide adenine
  • Associated conditions
    • malnutrition
      • Wernicke encephalopathy
      • Korsakoff syndrome
    • hepatic encephalopathy
Presentation
  • Patients are typically asymptomatic
    • symptoms depend how severe the liver damage is and if the patient developed cirrhosis
  • Symptoms/physical exam
    • palmar erythema
    • gynecomastia
    • testicular atrophy
    • spider angiomas
    • jaundice
    • caput medusae
    • hematemesis or melena
Imaging
  • Abdominal ultrasound
    • indication
      • to evaluate liver morphology, which may demonstrate hepatic steatosis or cirrhosis
Studies
  • Serum labs
    • aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
      • elevated AST to ALT ratio > 2  
    • γ-glutamyl transpeptidase (GGT)
      • often elevated
        • not specific for alcoholic liver disease
    • macrocytosis
      • suggestive of longstanding disease
      • secondary to decreased vitamin B12 or folate deficiency or alcoholic toxicity
Differential
  • Viral hepatitis
    • differentiating factors
      • significantly elevated AST and ALT
      • positive hepatitis testing
Treatment
  • Conservative
    • cessation of alcohol
      • indication
        • all patients with alcoholic liver disease
        • associated with improved outcomes
    • nutritional therapy
      • indication
        • vitamin replacement
  • Medical
    • glucocorticoids
      • indication
        • severe alcoholic hepatitis
  • Surgical
    • liver transplantation
      • indication
        • in patients with decompensated liver disease
Complications
  • Gastroesophageal varices
    • secondary to portal hypertension
  • Hepatocellular cancer
  • Ascites
    • can result in spontaneous bacterial peritonitis
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(M1.GI.13.134) A 39-year-old Caucasian male presents for a physical exam. It is noticed that he has slight hepatomegaly. During the history, the patient states he drinks 7-8 beers daily. Biopsy of the liver is shown in Figure A. What is the primary mechanism for the abnormality seen in Figure A? Tested Concept

QID: 101191
FIGURES:
1

Increased production of NAD

16%

(18/111)

2

Decreased production of NAD

39%

(43/111)

3

Increased fatty acid oxidation

16%

(18/111)

4

Increased synthesis and exportation of lipoproteins

7%

(8/111)

5

Increased uptake of fat

19%

(21/111)

M 1 E

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