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Alcoholic Liver Disease

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Overview

Alcoholic liver disease (ALD) is an umbrella term for the liver complications that can arise secondary to excess alcohol consumption including fatty liver (steatosis), alcoholic hepatitis (inflammation and hepatocyte death), and liver cirrhosis.

Alcohol recommendations

A summary of the recommendations surrounding alcohol are as follows:

  • Both men and women should drink no more than 14 units of alcohol per week
  • If people are to drink 14 units of alcohol per week, they should spread it evenly over 3 days
  • Pregnant people should not drink

The ‘alcohol by volume’ (ABV) measurement is the percentage of a drink that is ethanol. One unit of alcohol is 10 ml of ethanol. For example:

  • A 500 ml drink (5% ABV) has 500 x 0.10 = 25 ml alcohol in it, which is 2.5 units

Presentation

Some patients may be asymptomatic if they have mild steatosis. Features may be:

  • Right upper quadrant abdominal pain
  • Hepatomegaly
  • Features of advanced liver disease:

Differential Diagnoses

Viral hepatitis

  • There may be the presence of risk factors (e.g. eating undercooked meat or intravenous drug use
  • ALT is usually higher than AST in non-alcoholic hepatitis

Investigations

  • Full blood count:
    • Haemoglobin may be low due to gastrointestinal bleeds from varices/coagulopathy
    • There may be thrombocytopenia
  • Liver function tests (LFTs):
    • Bilirubin may be elevated
      • AST and ALT are elevated, AST: ALT ratio >2 – a helpful way of remembering this is ‘I propose a toAST’
    • Gamma-glutamyl transferase (GGT) – usually elevated
      • Since there is not much GGT in bone, a high ALP and GGT suggest that the ALP is from the liver
    • ALP may be raised if there is associated cholestasis
    • Albumin may be low – suggests impaired liver function
  • Prothrombin time and international normalised ratio (INR):
    • May be normal or prolonged – a prolonged result suggests impaired liver function
  • Liver ultrasound scan:
    • Used to monitor for the development of hepatocellular carcinoma
    • May show hepatomegaly, steatosis, cirrhosis, masses, and may show splenomegaly

Management

Overview

  • If acute episode of hepatitis: prednisolone is 1st-line
  • Weight reduction, alcohol abstinence and withdrawal, and other relevant lifestyle changes are important 

Complications

  • Liver cirrhosis and its complications. See Liver Cirrhosis for more detail.

Prognosis

  • The prognosis varies depending on what stage of alcoholic liver disease the patient is at. Those with steatosis have a better prognosis than those with cirrhosis.
  • The Maddrey discriminant function (MDF) can be used to assess the prognosis. It is a score based on the prothrombin time and total bilirubin, and a higher score indicates a worse prognosis.

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