Alcoholic Liver Disease

As the name implies it is liver disease caused as a result of excessive alcohol intake for a long duration. The quantity of alcohol to cause liver disease may vary for individuals and same is the duration of intake. Generally consumption of more than 20 units a week (one unit is one bottle of beer or a glass of wine or a peg of whisky) of alcohol for more than 10 years can lead to cirrhosis. Alcohol related liver disease can present in three ways:

Irrespective of way of presentation the first step is to totally avoid alcohol intake. Acute Alcoholic hepatitis patients need admission to a hospital and management in ICU setting. The patients with established cirrhosis may or may not need a liver transplant depending on clinical decision of treating doctor.

Alcohol-induced liver disease presents as a spectrum, to fit into one of these categories:

Fatty liver (Stage I)

Fatty liver, which occurs after acute alcohol ingestion, is generally reversible with abstinence and is not believed to predispose to any chronic form of liver disease if abstinence or moderation is maintained. Although fatty liver is a universal finding among heavy drinkers, up to 40% of those with modest alcohol intake (≤10 g/day) also exhibit fatty changes.

Alcoholic hepatitis (Stage II)

Alcoholic hepatitis is an acute form of alcohol-induced liver injury that occurs with the consumption of a large quantity of alcohol over a prolonged period of time; it encompasses a spectrum of severity ranging from asymptomatic derangement of biochemistries to fulminant liver failure and death.

A daily alcohol intake of 40 g is necessary to produce pathologic changes of alcoholic hepatitis. Consumption of more than 80 g per day is associated with an increase in the severity of alcoholic hepatitis.

Cirrhosis (Stage III)

Cirrhosis involves replacement of the normal hepatic parenchyma with extensive thick bands of fibrous tissue and regenerative nodules, which results in the clinical manifestations of portal hypertension and liver failure.

There is a clear dose-dependent relation between alcohol intake and the incidence of alcoholic cirrhosis. A daily intake of more than 60 g of alcohol in men and 20 g in women significantly increases the risk of cirrhosis.

Diagnosis

The diagnosis of alcohol liver disease requires thorough review of the medical history of the individual. Sometimes the inputs of family members or significant others is more forthcoming. The most notable point is the long standing history of alcohol intake.

The diagnosis of various stages of alcoholic Liver disease is as follow:

Fatty Liver

Mostly diagnosed as a part of evaluation of either elevated liver function tests or general health check up. No blood tests can diagnose fatty liver. Ultrasonography reveals fatty liver, which some centers grade as Grade I-III depending on the echogenecity.

Fatty liver is not specific to alcohol ingestion; it is associated with obesity, insulin resistance, hyperlipidemia, malnutrition, and various medications. Attribution of fatty liver to alcohol use therefore requires a detailed and accurate patient history.

Alcoholic Hepatitis

The diagnosis of alcoholic hepatitis is also based on a thorough history, physical examination, and review of laboratory tests. Characteristically, the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) is approximately 2:1 and the absolute aminotransferase level does not exceed ~300 U/L unless a superimposed hepatic insult exists, such as acetaminophen toxicity. Other common and nonspecific laboratory abnormalities include anemia and leukocytosis. Fibroscan has been utilized recently to establish the degree of fibrosis as a non invasive tool. Liver biopsy is occasionally necessary to secure the diagnosis.

Cirrhosis

The diagnosis of alcoholic cirrhosis again is achieved after obtaining detailed medical history of significant alcohol intake from the patient or the family members. This along with the presence of the classic signs and symptoms of end-stage liver disease helps us to achieve the final conclusion. Deranged blood investigations like LFT, prothrombin time, anemia, decreased platelet count all further help in assessing the disease severity. Ultrasonography, fibroscan, MRI or CT scan are imaging modalities utilized to study liver morphology, presence of portal hypertension, ascites or HCC.

Endoscopy is utilized to se presence of enlarged veins(varices) in esophagus or stomach.

Liver biopsy it is the gold standard to establish the diagnosis of cirrhosis. This requires taking tissue samples from the liver (from the body for examination under a microscope.

Treatment for alcoholic liver disease

The most important step in treatment of alcohol induced liver disease is abstaining from alcohol. This is also the most difficult step for the person concerned. This requires strong determination by the patient. It also needs a lot of social support and in many requires help of clinical psychologist. Some patients benefit from rehabilitation centers to finally achieve unsupervised abstinence.

Fatty liver disease and early stages of alcoholic hepatitis can be reversed by abstinence. Nutritional supplements and supportive medicines is required to help reverse this stage. Liver by itself has great potential to heal provided the inciting factor is removed. The use of steroids in alcoholic hepatitis has shown contradicting results. It should be tried in centers with high level of expertise.

In patients who have established cirrhosis, the disease is irreversible. The disease will progress rapidly if the individual continue to drink. Avoiding alcohol can halt the process or slow down the deterioration. These individuals need supportive medical care and have nutritional deficiencies which need correction.

Treatment of these patients with alcoholic cirrhosisis same as for any patients with any other type of cirrhosis, and includes prevention and management of ascites, spontaneous bacterial peritonitis, variceal bleeding, encephalopathy, malnutrition, and hepatocellular carcinoma. Once advanced cirrhosis has occurred with evidence of decompensation (ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, variceal bleeding), the patient should be referred to a transplantation center to be considered for liver transplantation.