Alcoholic liver disease is damage to the liver and its function due to alcohol abuse. Alcoholic hepatitis (AH) is a devastating acute form of ALD that requires early . in the morning to steady your nerves or to get rid of a hangover (eye opener)?. Alcoholic liver disease (ALD) encompasses a spectrum Alcohol remains a major cause of liver disease world- .. or to get rid of a hangover (eye-opener)?.
Alcohol Liver Disease What (ALD)? Is
Talk openly to your provider about your alcohol intake. The provider can counsel you about how much alcohol is safe for you. Ferri's Clinical Advisor Disorders of the liver and biliary tract. Concepts and Clinical Practice. Loss of energy Poor appetite and weight loss Nausea Belly pain Small, red spider-like blood vessels on the skin As liver function worsens, symptoms may include: Fluid buildup of the legs edema and in the abdomen ascites Yellow color in the skin, mucous membranes, or eyes jaundice Redness on the palms of the hands In men, impotence, shrinking of the testicles, and breast swelling Easy bruising and abnormal bleeding Confusion or problems thinking Pale or clay-colored stools.
Your health care provider will do a physical exam to look for: An enlarged liver or spleen Excess breast tissue Swollen abdomen, as a result of too much fluid Reddened palms Red spider-like blood vessels on the skin Small testicles Widened veins in the abdomen wall Yellow eyes or skin jaundice Tests you may have include: Abdominal CT scan Blood tests for other causes of liver disease Ultrasound of the abdomen. Eat a healthy diet that is low in salt. Get vaccinated for diseases such as influenza, hepatitis A and hepatitis B, and pneumococcal pneumonia.
Talk to your provider about all medicines you take, including herbs and supplements and over-the-counter medicines. Bleeding disorders coagulopathy Buildup of fluid in the abdomen ascites and infection of the fluid bacterial peritonitis Enlarged veins in the esophagus, stomach, or intestines that bleed easily esophageal varices Increased pressure in the blood vessels of the liver portal hypertension Kidney failure hepatorenal syndrome Liver cancer hepatocellular carcinoma Mental confusion, change in the level of consciousness, or coma hepatic encephalopathy.
When to Contact a Medical Professional. Contact your provider if you: Develop symptoms of alcoholic liver disease Develop symptoms after a long period of heavy drinking Are worried that drinking may be harming your health Get emergency medical help right away if you have: Liver disease due to alcohol; Cirrhosis or hepatitis - alcoholic; Laennec's cirrhosis. Digestive system Liver anatomy Fatty liver, CT scan.
Alcoholism and Alcohol Abuse Read more. A number of novel targeted therapies for ALD are currently being evaluated in clinical trials. Alcohol is consumed in most regions of the world and is a leading cause of liver disease. It is responsible for over 2. An additional 80, deaths resulted from alcohol-related hepatocellular carcinoma. Patterns of alcohol consumption vary widely between different parts of the world and are affected by the local culture and habits.
The duration of alcohol intake and amount of ingested alcohol are the most important predictors for the development of ALD. It is important to understand that ALD represents a spectrum of liver pathology that starts with fatty liver change, which is present in almost all heavy alcohol drinkers and is generally asymptomatic.
Alcohol is a leading cause of cirrhosis and its subsequent complications, including portal hypertension, ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome. In this article, we review the diagnostic evaluation of patients with ALD with an emphasis on alcoholic hepatitis, discuss the current management options for these patients, and highlight new developing therapies.
Early and accurate diagnosis of ALD is of paramount importance to provide these patients with the opportunity to reinforce the management of alcohol abuse, perform other lifestyle changes that can alter the progression of their liver disease, and provide specific screening protocols for cirrhosis-related complications, including esophageal varices and hepatocellular carcinoma.
Clinically, patients with ALD may exhibit the classical signs of liver disease, including parotid gland enlargement, gynecomastia, Dupuytren's contracture, dilated abdominal wall veins, and spider angiomas; but these are neither highly sensitive nor specific for ALD. A major challenge in the diagnosis of ALD is that patients with only fatty liver are usually asymptomatic and maintain an intact synthetic hepatic function. During the initial evaluation of suspected ALD, special attention to alcohol intake screening is warranted.
A very recent report from the Centers for Disease Control and Prevention concluded that only one of six US adults, including binge drinkers, reported ever discussing alcohol consumption with a health professional. Since it is short, simple, and easy to administer, the CAGE test remains one of the most widely used screening tools Table 1. It has 10 questions exploring alcohol consumption, dependence, and alcohol related problems, and two cut-off points, one for dependence and one for risky drinking.
Item responses are scored 0 No or 1 Yes , with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. Sum the scores for each of the 10 questions. It is important to distinguish patients with ALD from those with nonalcoholic fatty liver disease NAFLD who have evidence of hepatic steatosis without a cause for secondary hepatic fat accumulation and patients with nonalcoholic steatohepatitis NASH who have evidence of liver tissue inflammation with hepatocyte injury with or without fibrosis.
Therefore, an initial step in evaluating patients with ALD is the documentation of heavy alcohol consumption. Several biochemical markers have been utilized for this purpose, including aspartate aminotransferase AST , alanine aminotransferase ALT , mean corpuscular volume, carbohydrate deficient transferrin CDT , and gamma glutamyl transferase GGT.
Evaluation for the presence and degree of liver fibrosis in patients with ALD is of paramount importance. Liver biopsy remains the gold standard diagnostic modality for detecting and staging liver fibrosis; however, it has its own limitations, including expense, sampling errors, and inter-observer variability, which could lead to understaging of cirrhosis.
The percutaneous approach is especially painful and carries the risk of rare but serious complications, such as bleeding, infection, pneumothorax, hemothorax, and organ puncture. Several studies have evaluated the role of liver stiffness measurement LSM as a reliable noninvasive modality for assessing liver fibrosis in patients with ALD.
This system includes a probe with an ultrasonic transducer mounted on a vibrator. A low-frequency mild-amplitude vibration is transmitted from the vibrator to the liver tissue by the transducer. This vibration induces an elastic wave that propagates through the tissue. Ultrasonic acquisitions are simultaneously performed to follow the propagation of the wave and measure its velocity. The wave velocity is directly related to tissue stiffness the harder the tissue, the faster the wave propagation.
The cornerstone of ALD management at any stage is abstinence from alcohol. Improvement in fatty liver histology can occur as early as 2 weeks following discontinuation of alcohol use, while continuous alcohol consumption has been shown to increase portal pressure and worsen complication of portal hypertension, including variceal bleeding. Protein-calorie malnutrition is a common finding in patients with ALD. Therefore, a careful evaluation of the nutritional status of these patients is important and proper nutrition should be emphasized.
Addressing vitamins and trace minerals deficiencies e. Alcohol withdrawal syndrome is a serious condition that can complicate chronic alcoholism when patients suddenly decrease or discontinue their alcohol use. Within the first day after alcohol cessation, an increase in heart rate and blood pressure as well as irritability and hyperreflexia can occur. This can progress over the next few days to more severe complications, including seizures and delirium tremens.
Benzodiazepines or clomethiazole are typically used to manage alcohol withdrawal, but other agents like gabapentin, clonidine, topiramate, and baclofen are also being utilized to avoid the potential side effects of benzodiazepines.
Brief motivational interventions should be routinely used in the management of alcohol use disorders, while individuals with heavy alcohol use benefit from early referral to alcohol rehabilitation programs that provide psychotherapy to promote initiation and maintenance of alcohol abstinence. Twelve step facilitation and cognitive-behavioral coping skills therapies have been utilized for this purpose with comparable outcomes.
Pharmacological agents can complement psychosocial treatments for alcoholism. Disulfiram, an inhibitor of acetaldehyde dehydrogenase that leads to an unpleasant reaction when alcohol is consumed, has been traditionally used in alcoholics. However, its use in ALD has been hindered by potential hepatotoxicity. Naltrexone opioid receptor antagonist , acamprosate glutamatergic receptor modulator , and topiramate anticonvulsant have also demonstrated efficacy in management of alcoholism, but they have not been evaluated in patients with end stage liver disease and are therefore not recommended in patients with ALD.
Baclofen, a GABA receptor agonist, is a promising agent for increasing abstinence rates in alcoholic individuals and has demonstrated both efficacy and safety in patients with alcoholic cirrhosis. Alcoholic hepatitis is a well-defined severe form of ALD that requires specialized medical care.
An important concept in the management of alcoholic hepatitis is the assessment of disease severity. Several scoring systems have been developed for this purpose and demonstrate correlation with the clinical outcomes of those patients.
The mDF was the first score developed and is the most widely used. The Lille score includes six variables age, albumin, bilirubin at day 0, bilirubin day 7, presence of renal insufficiency, and prothrombin time and can be used to assess the response to corticosteroids after 1 week of treatment. Lille score values over 0. Infection screening is warranted in patients with alcoholic hepatitis, as a quarter of them are infected at the time of admission.
While antibiotics are frequently used in this clinical setting, randomized clinical trials for empiric antibiotics use in these patients are lacking. The response to corticosteroids is assessed at 1 week of treatment using the Lille score.
Importantly, infections are more likely to occur if corticosteroids are continued beyond the first week in null-responders i. However, corticosteroid therapy should not be precluded in infected patients after initiation of appropriate antibiotic therapy.
The survival benefit of pentoxifylline is mainly related to a reduction in the incidence of hepatorenal syndrome as the cause of death in these patients. In addition to the general ALD therapeutic measures outlined earlier, patients with alcoholic cirrhosis require treatment for cirrhosis-specific complications while evaluating their candidacy for liver transplantation. Given the relatively high risk for hepatocellular carcinoma in those patients, screening is emphasized, as for any patient with liver cirrhosis.
Given the shortage of donors and the risk of recidivism with consequent disease recurrence in the allograft, liver transplantation in patients with ALD has been an area of great medicosocial controversy.
However, with the emergence of strong evidence of genetic and environmental influences on alcohol dependence, the view on alcoholism and ALD as being self-inflicted is slowly being reconciled. ALD is currently the second most common indication for liver transplantation in the US, surpassed only by chronic hepatitis C virus infection. Alcoholics who receive liver transplants usually fair well, with similar graft and patient survival rates when compared to patients transplanted for nonalcohol related liver diseases.
This 6 month rule aims to allow patients with decompensated cirrhosis to recover from their liver disease and not require transplantation as well as to exclude the subset of patients who are at highest risk for recidivism, as demonstrated by psychological assessment.
Therefore, screening for these conditions before and after liver transplantation is essential. Patients with severe alcoholic hepatitis who fail medical therapy represent a particularly challenging group with regard to liver transplantation, as almost all are active drinkers at the time of presentation and many will have died by 6 months.
One study utilizing the United Network for Organ Sharing database, demonstrated almost equal 5 year post-transplant graft and patient survival rates in patients with alcoholic hepatitis and alcoholic cirrhosis: The progressive understanding of the underlying molecular basis of ALD has led to the development of a number of novel therapeutic targets for these patients.
Specific molecular pathways related to ALD include oxidative stress, endotoxin and cytokine production, and certain immune regulators. A number of clinical trials evaluating these novel agents in patients with severe alcoholic hepatitis are already underway. Interleukin IL is a promising therapeutic target for alcoholic hepatitis that has been associated with a reduction in hepatic steatosis following acute ethanol ingestion in animal models.
IL has also been shown to protect against hepatocyte injury and promote liver regeneration. However, IL should be cautiously used in patients with alcoholic cirrhosis due to the concern for the development of hepatocellular carcinoma. Lipopolysaccharides derived from gram negative enteric bacteria promote Kupffer cells activation and subsequent production of several hepatoinjurious cytokines. Bovine colostrum enriched with IgG antilipopolysaccharide will be evaluated in combination with prednisolone in patients with severe alcoholic hepatitis.
Anakinra an IL-1 receptor antagonist with anti-inflammatory activity in combination with pentoxifylline and zinc will be compared to methylprednisolone in a clinical trial recruiting patients with severe alcoholic hepatitis. The role of probiotics in moderately severe alcoholic hepatitis is also being explored. ALD is a major health problem with rising incidence and prevalence. Early diagnosis is required to reinforce alcohol abstinence and improve patient survival.
Clinical and laboratory diagnosis of ALD is enhanced by the emergence of a number of noninvasive diagnostics modalities, including biochemical panels and imaging techniques that measure liver stiffness. Subsequently, the diagnostic role of liver biopsy in ALD might diminish over time. Management of ALD relies on abstaining from alcohol while treating alcohol withdrawal, providing nutritional support, and managing cirrhosis-related complications.
Liver transplantation is the best available option for patients with alcoholic cirrhosis as long as they abstain from alcohol. Alcoholic hepatitis is a severe form of ALD associated with high mortality.
Patients with severe alcoholic hepatitis who fail medical therapy have very poor outcomes. New treatment agents for severe alcoholic hepatitis are under development, and the role of early liver transplantation in highly selected patients requires further research.
National Center for Biotechnology Information , U. J Clin Transl Hepatol. Published online Jun Author information Article notes Copyright and License information Disclaimer. Contributed by Author contributions: This article has been cited by other articles in PMC. Abstract Alcohol is a leading cause of liver disease and is associated with significant morbidity and mortality.
Alcoholism, Alcoholic cirrhosis, Alcoholic hepatitis, Liver transplantation. Introduction Alcohol is consumed in most regions of the world and is a leading cause of liver disease.
Open in a separate window. Diagnosis Early and accurate diagnosis of ALD is of paramount importance to provide these patients with the opportunity to reinforce the management of alcohol abuse, perform other lifestyle changes that can alter the progression of their liver disease, and provide specific screening protocols for cirrhosis-related complications, including esophageal varices and hepatocellular carcinoma.
Diagnosis and Management of Alcoholic Liver Disease
Alcoholic liver disease (ALD) is one of the major medical complications of alcohol abuse. Alcohol is the major cause of liver cirrhosis in the Western world, with. Alcohol-related liver disease (ARLD) refers to liver damage caused by excess alcohol intake. There are several stages of severity and a range of associated. Alcoholic liver disease (ALD) comprises a clinical-histologic spectrum including .. anxious, or edgy? and (b) not being able to stop or control worrying (39)? On .