Alcoholic liver disease remains the
second most common indication for liver transplantation and can present in
varying ways along a spectrum of disease (Varma). Acute alcoholic
hepatitis is an important clinical entity that can present in both mild and severe
forms, and it is clinically distinct from more chronic forms of liver such as
alcoholic cirrhosis. Prompt recognition is critical, as this diagnosis can be
associated with an extremely high short-term mortality without appropriate
treatment 1. In this paper, we review the clinical
presentation and diagnosis of alcoholic hepatitis, as well as current available
therapy, with particular emphasis on the increasing role of liver
transplantation.

 

Spectrum of Alcoholic Liver Disease

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Though there are a
number of genetic and environmental factors that influence the degree of
alcohol intake needed to induce liver dysfunction, consumption of greater than
60-80 g/day of alcohol for at least 10 years in men or at least 20 years in
women has been linked to increased risk of the development of alcoholic liver
disease 2 (also Mandayam, epidemiology of alcoholic
liver disease, 2004 and Bellentani Drinking habits as cofactors for alcohol
induced liver damage, 1997).

 

Alcoholic fatty liver

Alcoholic fatty
liver is the first manifestation of excessive alcohol consumption and is the most
common presentation of alcoholic liver disease, occurring in up to 80% of heavy
drinkers 3. Patients are often asymptomatic and the
physical exam is typically normal or notable only for hepatomegaly. On
laboratory testing, patients may have mild elevations in aspartate
aminotransferase (AST, typically less than 8 times the upper limit of normal)
and alanine aminotransferase (ALT, typically less than 5 times the upper limit
of 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 with
longstanding 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 notable
for steatosis with  macrovesicular
changes (Crabb DW pathogenesis of alcoholic liver disease: newer mechanisms
of injury 1999). Diagnosis is typically made based upon history in
combination with laboratory and imaging studies, though it is important to
distinguish this disease entity from other conditions that may lead to a
similar clinical presentation, including viral hepatitis, NAFLD, drug-induced
liver injury, and more rare entities such as alpha-1-anti-trypsin deficiency,
hemachromatosis, or Wilson’s disease. Alcoholic fatty liver disease may resolve
after 1 to 2 months of alcohol abstinence 2.

 

Alcoholic cirrhosis

If heavy alcohol consumption continues, alcoholic
fatty liver disease can progress to cirrhosis in up to 30% of patients 4. Patients with cirrhosis can present with a
variety of symptoms, including fatigue, abdominal distension, lower extremity
edema, 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 (Heidelbaugh
and Bruderly, Cirrhosis and Chronic Liver Failure, am family physician 2006).

In
addition 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 in
creatinine (citation). ImagingMM1 , again via
ultrasound, 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 of
collateral veins (Childers, Ahn, Diagnosis of alcoholic liver disease 2016).

 

Alcoholic hepatitis

Alcoholic hepatitis
represents an acute deterioration of hepatic function in the setting of
longstanding heavy alcohol use (typically greater than 100 g/day for at least
20 years) in patients with or without known cirrhosis 5. Indeed, more than half of patients with
alcoholic hepatitis may have concomitant cirrhosis liver on biopsy or will
develop cirrhosis during the natural course of their disease 2. The clinical presentation and diagnosis is
described below.

 

Clinical Presentation and Diagnosis

 MM1These
lab findings are also seen in alc hep

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