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  • In the United States, excessive alcohol use is defined as ingestion of >14 drinks/week in women and >21 drinks/week in men (1 drink = 12 oz beer, 1.0 oz malt liquor, 5 oz wine, or 1.5 oz 80 proof "hard liquor").
  • Factors accelerating liver injury in alcoholic liver disease (ALD) include female gender, Latino and African-American ethnicity, chronic hepatitis C infection, acetaminophen overdose, and hereditary hemochromatosis.
  • 75% of Asians have decreased ability to metabolize ethanol, resulting in acetaldehyde accumulation and subsequent flushing.
  • Diagnosis of excessive alcohol use is suggested by increased serum ALT and AST levels, AST:ALT ratio of 2–3:1, and MCV >100.
  • Accurate history of substance intake and CAGE or Alcohol Use Disorders Identification Test (AUDIT) questionnaires aid in the diagnosis of alcohol abuse.
  • Liver biopsy and liver imaging cannot distinguish ALD from nonalcoholic steatohepatitis (NASH).
  • Although 90–100% of heavy drinkers will develop hepatic steatosis, only 10–35% will develop alcoholic hepatitis, and 5–15% will develop cirrhosis.

Alcohol use in human history has played an important role in social interactions, politics, religion, medicine, and nutrition. The first use of alcohol dates back to the late stone-age Neolithic period (circa 10,000 BC) with the archeological discovery of beer jugs. Egyptian pictographs suggest wine consumption as early as 4000 BC. The use of wine and beer for medical purposes began circa 2000 BC. Sentiment toward moderation in drinking was documented in a Chinese imperial edict in the 12th century BC. The association of alcohol with liver disease appeared to have been noticed by the ancient Egyptians, who linked the use of beer with ascites, and the ancient Greeks, who described the association with jaundice and gastrointestinal bleeding.

Incidence and Societal Costs

Alcohol-related health problems contribute to significant health care costs worldwide. In 2003, the prevalence of alcohol-related disorders was 1.7% worldwide, and alcohol was the third leading cause of death in the United States. Data from the NIH-sponsored NESARC study suggest that 4.65% and 3.81% of American adults meet the criteria for alcohol abuse and alcohol dependence, respectively. Studies have shown that per capita alcohol consumption in both men and women is associated with mortality from liver cirrhosis.

Not all those who consume alcohol will develop Alcoholic Liver Disease (ALD) and liver cirrhosis. Among heavy drinkers, 90–100% will develop hepatic steatosis in 10 years, but only 10–35% will develop steatohepatitis and 5–15% will develop cirrhosis in the same period (Figure 42–1).

Figure 42–1.

Progression of alcoholic liver disease. (Reproduced, with permission, from McCullough AJ, O'Connor JF. Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology. Am J Gastroenterol. 1998;93:11.)


Epidemiologic research involving alcohol use is not without limitations. The definition of one alcohol drink varies globally and individually. In the United States, the definition used by the Centers for ...

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