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alcoholic liver disease (ALD)

Epidemiology: -> most alcoholics do NOT develop significant liver disease Pathology: 1) alcohol induces hepatic microsomal enzymes 2) enhanced risk of acetaminophen-induced hepatitis 3) risk factor for progression to cirrhosis: a) excessive daily alcohol consumption b) long duration of alcoholism c) beverage type d) female sex e) concurrent HIV infection f) > 160 g of ethanol/day (> 14 oz of 80 proof whiskey/day) for > 10 years places patient at greatest risk for end- stage liver disease Clinical manifestations: 1) portal hypertension a) splenomegaly b) ascites 2) spider angioma 3) palmar erythema Laboratory: 1) complete blood count (CBC) 2) prothrombin time/INR may be prolonged 3) liver function tests may be abnormal a) decreased serum albumin b) increased serum ALT, serum AST with AST/ALT often > 2 c) increased serum bilirubin, serum GGT, serum ALP 4) serum cholesterol may be diminished 5) screening for hepatocellular carcinoma with serum alpha-fetoprotein is not recommended because of poor sensitivity & specificity (may be used in conjunction with abdominal ultrasound for screening) Special laboratory: - upper GI endoscopy to screen for esophageal varices [4] - repeat screening upper GI endoscopy in 2-3 years if no varices [4] Radiology: - abdominal ultrasound (evaluation of cirrhosis & screening for hepatocellular carcinoma) [2,4] - transient elastography to assess hepatic fibrosis [5] Complications: - increased risk of upper GI bleeding a) esophageal varices b) gastritis c) gastric & duodenal ulcers d) Mallory-Weiss tear Management: 1) stop drinking 2) specific treatment for specific complications 3) adequate nutrition (2000 kcal/day) 4) refer patients with advanced alcoholic liver diseased foor management & consideration of liver transplantation regardless of duration of abstinence from alcohol [1] 5) liver transplantation a) abstinence from alcohol for > 6 monthy to 1 year b) good social support 6) baclofen effective in preventing alcohol relapse in patients with alcoholic liver disease [2] 7) nonselective beta-blocker or endoscopic variceal ligation for esophageal varices

Related

alcoholism (includes binge drinking) cirrhosis esophageal varices upper gastrointestinal hemorrhage

Specific

alcoholic cirrhosis alcoholic hepatitis

General

liver disease

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 19. American College of Physicians, Philadelphia 1998, 2012, 2021.
  2. Singal AK, Bataller R, Ahn J, Kamath PS, Shah VH. ACG clinical guideline: Alcoholic liver disease. Am J Gastroenterol 2018 Jan 16 PMID: 29336434
  3. European Association for the Study of the Liver EASL Clinical Practice Guidelines: Management of alcohol- related liver disease. J Hepatol. 2018 Apr 5. pii: S0168-8278(18)30214-9 PMID: 29628280 https://www.journal-of-hepatology.eu/article/S0168-8278(18)30214-9/fulltext
  4. NEJM Knowledge+ Question of the Week. July 23, 2019 https://knowledgeplus.nejm.org/question-of-week/394/ - Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2017 Jan; 65:310. PMID: 27786365
  5. NEJM Knowledge+ Gastroenterology
  6. Crabb DW, Im GY, Szabo G, et al. Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2020;71:306-333. PMID: 31314133