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| | __NOTOC__ |
| | {{Alcoholic liver disease}} |
| | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{MKA}} |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| [[Image:Pathogenesis alcoholic liver injury.jpg|thumb|right|Pathogenesis of alcohol induced liver injury]]
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| {{CMG}}
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| ==Overview==
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| {{alcohealth}}
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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
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| Image = Alcoholic_hepatitis.jpg |
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| Caption = [[Microscopy]] of [[liver]] showing fatty change, cell necrosis, [[Mallory body|Mallory bodies]]|
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| DiseasesDB = |
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| ICD10 = {{ICD10|K|70||k|70}}|
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| ICD9 = {{ICD9|571.1}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000281 |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D008108 |
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| }}
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| {{SI}}
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| '''Alcoholic liver disease''' is the major cause of [[liver disease]] in Western countries, (in Asian countries, viral [[hepatitis]] is the major cause). It arises from the excessive ingestion of [[Alcoholic beverage|alcohol]] and can present as [[fatty liver]], [[alcoholic hepatitis]], and [[cirrhosis]]. Fatty liver and alcoholic hepatitis are reversible with abstinence from alcohol. Alcoholic hepatitis involves acute or chronic inflammation of liver parenchyma and is the most common precursor of cirrhosis in the United States
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| ==Pathophysiology==
| | {{SK}} Alcoholic hepatitis; Alcoholic fatty liver disease; Fatty liver disease. |
| Fatty change and alcoholic hepatitis are probably reversible. The later stages of fibrosis and cirrhosis tend to be irreversible but can usually be quite well managed for long periods of time. | | |
| '''The cause of fatty change are:'''
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| * The excess generation of NAD by the enzymes alcohol dehydrogenase and aldehyde dehydrogenase which cause shunting of normal substrates from catabolism towards lipid biosynthesis.
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| * Impaired assembly and secretion of lipoproteins and increased peripheral lipid catabolism may also contribute
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| '''The cause of alcoholic hepatitis are:'''
| | ==[[Alcoholic liver disease overview|Overview]]== |
| *Acetaldehyde formed from alcohol induces lipid peroxidation and acetaldehyde protein adduct formation which disrupt cytoskeleton
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| *Directly affect microtubule organization, mitochondrial function and membrane fluidity
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| *Generation of ROS
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| *Neutrophil attack at the site of hepatocyte necrosis
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| ===Fatty change=== | |
| {{main|Fatty liver}}
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| * Fatty change, or [[steatosis]] is the accumulation of fat in [[hepatocyte|liver cells]] which can be seen as fatty globules under the microscope.
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| * [[Alcoholism]] causes large fatty globules (macrovesicular steatosis).
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| * Other causes of macrovesicular steatosis include [[diabetes]], [[obesity]] and [[starvation]].
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| * Alcoholic fatty change is probably dose related.
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| * Small fatty globules have different causes.
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| ===Alcoholic hepatitis=== | |
| {{main|Alcoholic hepatitis}}
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| * Some people get an acute hepatitis or inflammatory reaction to the cells affected by fatty change. This is not directly related to the dose of alcohol.
| | ==[[Alcoholic liver disease historical perspective|Historical Perspective]]== |
| * Some people seem more prone to this reaction than others. This is called alcoholic steatonecrosis and the inflammation probably predisposes to liver fibrosis.
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| ===Liver fibrosis===
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| * Liver fibrosis, in itself, is largely asymptomatic but as it progresses it can turn into [[cirrhosis]], where the fibrosis alters the architecture and impairs the function of the liver.
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| ===Cirrhosis ===
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| {{main|cirrhosis}}
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| * [[Cirrhosis]] is a late stage of liver disease marked by fibrosis and altered liver architecture.
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| * It is often progressive and may eventually lead to [[liver failure]].
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| * Late complications of cirrhosis or liver failure include [[portal hypertension]], [[coagulopathy|coagulation disorders]], [[ascites]] and other complications including [[hepatic encephalopathy]] and the [[hepatorenal syndrome]].
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| * [[Cirrhosis]] also has number of other causes, such as hepatitis and toxins. The late stages of cirrhosis (say from viral hepatitis or alcohol) may look similar. This phenomenon is termed a "final common pathway" for a disease.
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| ==Differential diagnosis== | |
| * [[Cholecystitis]]
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| * [[Cholelithiasis]]
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| * [[Drug toxicity]]
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| * [[Hepatitis]] (viral, autoimmune)
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| * [[Nonalcoholic fatty liver disease]]
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| ==History and symptoms== | | ==[[Alcoholic liver disease classification|Classification]]== |
| ===History===
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| * Recent history of heavy drinking
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| * Chronic alcohol intake i.e. > 80 g/d in men and 40 g/d in women with alcoholic hepatitis or cirrhosis.
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| ===Symptoms===
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| * Heaviness and pain below right side of chest (hepatomegaly)
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| * Abdominal pain
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| * Jaundice
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| * Anorexia
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| * Nausea/vomiting
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| ==Physical examination==
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| * Fever
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| * [[Jaundice]]
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| * Abdominal tenderness
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| * [[Hepatosplenomegaly]]
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| * [[Ascites]]
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| * Confusion, coma ([[encephalopathy]])
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| ==Lab diagnosis== | | ==[[Alcoholic liver disease pathophysiology|Pathophysiology]]== |
| ===Hemogram===
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| * Macrocytic Anemia
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| * Thrombocytopenia (causes are toxic effect of alcohol on platelet and splenomegaly)
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| * Leukocytosis
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| ===Liver function test===
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| * Raised serum bilirubin
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| * Elevated liver enzyme
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| ** '''AST usually elevated more than ALT (commonly by factor of 2 or more)'''
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| ** AST usually elevated but not more than 300 u/L
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| ** Elevated alkaline phosphatase (infrequently more than 3 times of normal)
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| * Prolonged prothrombin time (> 6 seconds above control)
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| * Serum protein
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| ** Decreased serum albumin
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| ** Increased gamma globulin
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| * Iron studies
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| ** Increased transferrin saturation, hepatic iron stores, and sideroblastic anemia
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| * Folic acid deficiency
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| ==Ultrasonography==
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| * Used for excluding biliary obstruction
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| * Ascites
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| ==CT scan== | | ==[[Alcoholic liver disease causes|Causes]]== |
| * To exclude pancreatic disease
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| * To exclude Space occupying lesions
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| * Collateral vessels
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| ==MRI== | | ==[[Alcoholic liver disease differential diagnosis|Differentiating Alcoholic liver disease from other Diseases]]== |
| * To exclude pancreatic disease
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| * To exclude space occupying lesions
| | ==[[Alcoholic liver disease epidemiology and demographics|Epidemiology and Demographics]]== |
| * Collateral vessels
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| ==Other studies== | | ==[[Alcoholic liver disease risk factors|Risk Factors]]== |
| ===Liver biopsy=== | | |
| * '''Fatty liver'''
| | ==[[Alcoholic liver disease screening|Screening]]== |
| ** Macrovesicular fat
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| * '''Alcoholic hepatitis'''
| | ==[[Alcoholic liver disease natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| ** Polymorphonuclear infiltration
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| ** Hepatic necrosis
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| ** [[Mallory bodies]] in hepatocytes
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| ** Perivenular and perisinusoidal fibrosis
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| ** Ballooning hepatocytes
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| ** Steatosis,
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| * '''Alcoholic cirrhosis'''
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| ** [[Micronodular cirrhosis]]
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| ==Treatment==
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| ===Medical therapy===
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| ====General==== | |
| * Abstinence from alcohol
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| * Counseling and family support during alcohol abstinence
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| * [[Naltrexone]] or [[acamprosate]] to reduce relapse
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| * Nutritional support - Adequate amounts of carbohydrates and calories as alcoholics are commonly malnourished. This prevents endogenous protein catabolism, and [[hypoglycemia]]. Administration of [[thiamine]] is important with glucose supplements. This is so because glucose administration increases B1 consumption and B1 deficiency may lead to [[Wernicke–Korsakoff syndrome]].
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| * [[Folic acid]], thiamine, and [[zinc]] supplements are recommended.
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| ==Prognosis==
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| In absence of steroid therapy 1 in every three patient dies.
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| ===Poor Prognostic factor===
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| * Prolonged prothrombin time
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| * Serum Bilirubin >10 mg/dL
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| * Hepatic encephalopathy
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| * Azotemia
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| * Leukocytosis
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| * Unresponsive to steroid treatment
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| * Reversal portal flow on doppler USG
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| ===Prognostic scores=== | | ==Diagnosis== |
| * MELD score for cirrhosis
| | [[Alcoholic liver disease history and symptoms|History and Symptoms]] | [[Alcoholic liver disease physical examination|Physical Examination]] | [[Alcoholic liver disease laboratory findings|Laboratory Findings]] | [[Alcoholic liver disease electrocardiogram|Electrocardiogram]] | [[Alcoholic liver disease x ray|X Ray]] | [[Alcoholic liver disease CT|CT]] | [[Alcoholic liver disease MRI|MRI]] | [[Alcoholic liver disease echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Alcoholic liver disease other imaging findings|Other Imaging Findings]] | [[Alcoholic liver disease other diagnostic studies|Other Diagnostic Studies]] |
| * Glasgow alcoholic hepatitis score (age, white blood cell, blood urea nitrogen, prothrombin time ratio, and bilirubin level)
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| * ABIC score - age, serum bilirubin, serum creatinine
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| ====Drug therapy==== | | ==Treatment== |
| =====Alcoholic hepatitis=====
| | [[Alcoholic liver disease medical therapy|Medical Therapy]] | [[Alcoholic liver disease Surgery|Surgery]] | [[Alcoholic liver disease primary prevention|Primary Prevention]] | [[Alcoholic liver disease secondary prevention|Secondary Prevention]] | [[Alcoholic liver disease cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Alcoholic liver disease future or investigational therapies|Future or Investigational Therapies]] |
| * '''Methylprednisolone'''
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| ** Decreases short term mortality
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| ** Usually given for 1 month
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| ** Serum [[bilirubin]] is used as a predictor for treatment success. Failure of the serum bilirubin level to decline after 7 days of treatment predicts poor prognosis
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| ** Another predictor of treatment is '''Lille model''' comprising, age, serum [[creatinine]], serum [[albumin]], [[prothrombin time]] (or INR), serum [[bilirubin]] on admission, and serum bilirubin on day 7
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| * '''Pentoxifylline'''
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| * It is a [[tumor necrosis factor]] inhibitor
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| * Used in patients with contraindications to steroids
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| * Usually given for 1 months
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| * Decreases mortality
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| * Decreases risk of [[hepatorenal syndrome]]
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| '''Other less commonly used drugs'''
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| * Steroids + [[N-acetylcysteine]]
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| * [[Propylthiouracil]]
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| * [[Oxandrolone]]
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| * [[S-adenosyl-L-methionine]]
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| * [[Infliximab]]
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| ==References== | | ==Case Studies== |
| {{reflist|1}} | | [[Alcoholic liver disease case study one|Case #1]] |
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| [[Category:Pathology]] | | [[Category:Surgery]] |
| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
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| [[Category:Hepatology]] | | [[Category:Hepatology]] |
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