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Patients may be asymptomatic, have incidentally discovered hepatomegaly or transaminase elevation, have symptoms of acute alcoholic hepatitis, or have manifestations of cirrhosis. Some or all of these symptoms may develop in an individual patient during the course of the disease.


  1. Alcohol ingestion is the most important risk factor for ALD.

    1. Beer and spirits are more associated with ALD than wine.

    2. Drinking outside of meal time and binge drinking increase the risk.

  2. Other risk factors include female sex, African-American and Hispanic ethnicity, obesity, and genetic factors.

  3. ALD is more frequent and worse in patients with other chronic liver diseases, especially hepatitis C.

  4. There are 3 histologic stages: steatosis, alcoholic steatohepatitis, and chronic hepatitis with fibrosis or cirrhosis.

    1. Hepatic steatosis is generally asymptomatic.

      1. 70% of patients have hepatomegaly

      2. Occurs in up to 90% of patients who consistently consume > 6 drinks (60 g) per day

      3. Potentiates liver damage from other insults, such as viral hepatitis or acetaminophen toxicity, and promotes obesity-related liver disease.

      4. Usually completely reversible with abstinence from alcohol for 4–6 weeks

        1. Despite abstinence, cirrhosis will develop in 5–15% of patients with steatosis.

        2. Cirrhosis develops in 30% of those who continue to drink.

    2. Alcoholic steatohepatitis occurs in 15–30% of patients with ALD.

      1. Often presents acutely in the context of chronic liver disease

      2. Symptoms often include fever, hepatomegaly, ascites, encephalopathy, AST:ALT ratio > 1.5, and leukocytosis, all in the context of heavy alcohol use.

      3. Malnutrition is seen in 90% of patients.

      4. Concomitant cirrhosis is found in > 50% of patients with alcoholic hepatitis.

      5. 3-month mortality between 15% (mild alcoholic hepatitis) and 55% (severe alcoholic hepatitis)

      6. Several tools have been developed to risk stratify patients with alcoholic hepatitis.

        1. The Modified Discriminant Function (mDF) = 4.6 × (patient PT − control PT) + serum bilirubin level: patients with a score ≥ 32 have a poor prognosis

        2. The Mayo End-stage Liver Disease (MELD) score incorporates the total bilirubin, international normalized ratio (INR), and serum creatinine (

          1. A MELD score > 11 is similar to an mDF ≥ 32 in predicting mortality.

          2. A MELD score > 20 1 week after admission had a sensitivity of 91% and specificity 85% for identifying patients who will die within 30 days.

        3. The Glasgow Alcoholic Hepatitis Score (GAHS) includes age, WBC count, BUN, PT/INR, and total bilirubin ( a score ≥ 9 is associated with a poor prognosis and has an accuracy of 81% in predicting 28-day mortality.

    3. Cirrhosis (also see Chapter 17-6: Cirrhosis)

      1. Increased risk in men who consume > 60–80 g/day and women who consume > 20 g/day of alcohol for ≥ 10 years. (One standard drink contains 14 g of alcohol.)

        1. Only 6–41% of such individuals develop cirrhosis

        2. Fibrosis develops in 40–60% of people who consume > 40–80 g/day for 25 years

      2. In patients without any other chronic liver disease, 21 drinks/week in men and 7–14/week in women probably will not lead to ALD.

      3. The prognosis of alcoholic cirrhosis varies, ...

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