Liver Disease, Alcohol-Associated

Key Features

Essentials of Diagnosis

• Chronic alcohol intake usually exceeds 80 g/day in men and 30–40 g/day in women with alcoholic hepatitis or cirrhosis

• Fatty liver is often asymptomatic

• In alcoholic hepatitis, fever, right upper quadrant pain, tender hepatomegaly, and jaundice; or asymptomatic

• Aspartate aminotransferase (AST) is often elevated, usually not above 300 units/L (6 mckat/L)

• AST is greater than alanine aminotransferase (ALT), often by a factor of 2 or more

• While alcoholic hepatitis is often reversible, it is the most common precursor of cirrhosis in the United States

General Considerations

• Excessive alcohol intake can lead to fatty liver, alcoholic hepatitis, and cirrhosis

• Many of the adverse effects of alcohol are probably mediated by tumor necrosis factor and by the oxidative metabolite acetaldehyde, which contributes to lipid peroxidation and induction of an immune response

• Alcoholic hepatitis is characterized by acute or chronic inflammation and parenchymal necrosis

• Deficiencies of vitamins and calories probably contribute to development of alcoholic hepatitis and its progression to cirrhosis

Demographics

• Incidence in the United States is rising fastest among persons aged 20–29, and the increase accelerated during the COVID-19 pandemic

• Over 80% of patients have been drinking 5 years or more before developing any liver symptoms

• The longer the duration of drinking (10–15 or more years) and the larger the alcohol consumption, the greater the probability of developing alcoholic hepatitis and cirrhosis

Clinical Findings

Symptoms and Signs

• Can vary from an asymptomatic hepatomegaly to a rapidly fatal acute illness (acute-on-chronic liver failure) or to an end-stage cirrhosis

• Recent period of heavy drinking

• Anorexia and nausea

• Hepatomegaly and jaundice in hepatitis

• Abdominal pain and tenderness, splenomegaly, ascites, fever, and/or encephalopathy in cirrhosis

• Infection, including invasive aspergillosis, is common in patients with severe alcoholic hepatitis

Differential Diagnosis

• Nonalcoholic fatty liver disease

• Viral hepatitis

• Drug-induced hepatitis

• Cirrhosis

• Biliary tract disease

• Cholecystitis

• Cholelithiasis

Diagnosis

Laboratory Tests

LIVER PANEL

• AST is usually elevated up to 400 units/L, but not higher

• AST is > ALT, usually by a factor of 2 or more

• Serum alkaline phosphatase is generally elevated, but seldom more than three times the normal value

• Serum bilirubin is increased in 60–90% of patients with alcoholic hepatitis

COMPLETE BLOOD COUNT

• Anemia (usually macrocytic) may be present

• Leukocytosis with shift to the left is common with severe alcoholic hepatitis

• Leukopenia is occasionally seen and resolves after cessation of drinking

• About 10% of patients have thrombocytopenia related to a direct toxic effect of alcohol on megakaryocyte production or to hypersplenism