Alcoholic liver disease remains thesecond most common indication for liver transplantation and can present invarying ways along a spectrum of disease (Varma).
Acute alcoholichepatitis is an important clinical entity that can present in both mild and severeforms, and it is clinically distinct from more chronic forms of liver such asalcoholic cirrhosis. Prompt recognition is critical, as this diagnosis can beassociated with an extremely high short-term mortality without appropriatetreatment 1. In this paper, we review the clinicalpresentation and diagnosis of alcoholic hepatitis, as well as current availabletherapy, with particular emphasis on the increasing role of livertransplantation.
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Spectrum of Alcoholic Liver DiseaseThough there are anumber of genetic and environmental factors that influence the degree ofalcohol intake needed to induce liver dysfunction, consumption of greater than60-80 g/day of alcohol for at least 10 years in men or at least 20 years inwomen has been linked to increased risk of the development of alcoholic liverdisease 2 (also Mandayam, epidemiology of alcoholicliver disease, 2004 and Bellentani Drinking habits as cofactors for alcoholinduced liver damage, 1997). Alcoholic fatty liver Alcoholic fattyliver is the first manifestation of excessive alcohol consumption and is the mostcommon presentation of alcoholic liver disease, occurring in up to 80% of heavydrinkers 3. Patients are often asymptomatic and thephysical exam is typically normal or notable only for hepatomegaly. Onlaboratory testing, patients may have mild elevations in aspartateaminotransferase (AST, typically less than 8 times the upper limit of normal)and alanine aminotransferase (ALT, typically less than 5 times the upper limitof normal), classically in a 2:1 pattern (Kazemi-Shirazi L, 2008,differentiation of non alc hep: https://link.springer.com/article/10.1007/s00508-007-0921-1).
Laboratory studies may also be notable for other findings associated withlongstanding alcohol use, including elevated gamma-glutamyl transpeptidase(GGT), elevated mean corpuscular volume (MCV), leukopenia, anemia and thrombocytopenia.Imaging via ultrasound, CT scan, or MRI may demonstrate hepatic steatosis.Biopsy is not necessary for diagnosis but if obtained, may be normal or notablefor steatosis with macrovesicularchanges (Crabb DW pathogenesis of alcoholic liver disease: newer mechanismsof injury 1999). Diagnosis is typically made based upon history incombination with laboratory and imaging studies, though it is important todistinguish this disease entity from other conditions that may lead to asimilar clinical presentation, including viral hepatitis, NAFLD, drug-inducedliver injury, and more rare entities such as alpha-1-anti-trypsin deficiency,hemachromatosis, or Wilson’s disease.
Alcoholic fatty liver disease may resolveafter 1 to 2 months of alcohol abstinence 2. Alcoholic cirrhosisIf heavy alcohol consumption continues, alcoholicfatty liver disease can progress to cirrhosis in up to 30% of patients 4. Patients with cirrhosis can present with avariety of symptoms, including fatigue, abdominal distension, lower extremityedema, shortness of breath, jaundice, and bleeding (hematemesis or melena).Physical exam findings vary depending on the patient and presence of decompensation,but can be notable for ascites, edema, palmar erythema, gynecomastia,testicular atrophy, caput medusa, telangiectasias, and splenomegaly (Heidelbaughand Bruderly, Cirrhosis and Chronic Liver Failure, am family physician 2006).Inaddition to the abnormal findings seen in patients with alcoholic hepatitis,patients with cirrhosis may also have an elevated international normalized ratio(INR), hyperbilirubinemia, hypoalbuminemia, hyponatremia and elevations increatinine (citation). ImagingMM1 , again viaultrasound, CT scan, or MRI, demonstrates a liver with a cirrhotic morphology,and findings may include nodularity and atrophy as well as ascites,splenomegaly, attenuation of hepatic vasculature, and the presence ofcollateral veins (Childers, Ahn, Diagnosis of alcoholic liver disease 2016).
Alcoholic hepatitisAlcoholic hepatitisrepresents an acute deterioration of hepatic function in the setting oflongstanding heavy alcohol use (typically greater than 100 g/day for at least20 years) in patients with or without known cirrhosis 5. Indeed, more than half of patients withalcoholic hepatitis may have concomitant cirrhosis liver on biopsy or willdevelop cirrhosis during the natural course of their disease 2. The clinical presentation and diagnosis isdescribed below. Clinical Presentation and Diagnosis MM1Theselab findings are also seen in alc hep