Definition: It is the destruction of the liver, ranging from fatty liver to cirrhosis, due to excessive alcohol consumption.
Pathogenesis:
• Alcohol is converted to acetaldehyde in the liver by MEOS (microsomal ethanol oxidizing system) and ADH (alcohol dehydrogenase).
• If acetaldehyde accumulates in the liver, hepatocellular injury begins.
• The most important determinant of alcohol-related liver damage is the amount and duration of alcohol intake.
Risk factors;
Amount: Ethyl alcohol > 20 g/day female, > 30 g/day male
Duration: 5-20 years
Other: Female gender, genetics, NASH, daily intake, smoking, malnutrition, HBV and HCV coexistence.
Clinic:
• Alcoholic liver disease can be seen in a wide clinical spectrum ranging from asymptomatic form to acute alcoholic hepatitis and cirrhosis.
• Disruptive hypertension, ascites and varicose bleeding can be seen in alcoholic liver disease without the development of cirrhosis.
• The clinical spectrum is quite broad:
Fatty liver (most common)
acute alcoholic hepatitis
Chronic liver disease (steatohepatitis and liver cirrhosis)
hepatocellular cancer
Activation of hepatitis B and C
Enhancement of the effect of other drugs and toxins
Laboratory and diagnosis:
• Macrocytosis is common and may be associated with or without anemia.
• Hemolytic anemia can be seen in severe alcoholic hepatitis (Zieve syndrome)
Aminotransferases may increase 2-7 fold (usually < 300-400 IU) and typically AST is higher than ALT (AST/ ALT > 2).
• An AST/ALT ratio above 3 is highly specific for alcoholic hepatitis.
• Plasma GGT level is usually high. ALP may be normal.
• An increase in immunoglobulin A is typical.
• Biopsy is the most valuable test in diagnosis and prognosis.
Prognosis:
Generally, the most important prognostic factor in a patient who drinks alcohol is whether the patient stops drinking alcohol or not.
• Maddrey score (discriminant factor) and MELD score are used to determine the prognosis in acute alcoholic hepatitis.
• Maddrey score evaluates PTZ and bilirubin increase: ( 4.6x [patient PTZ-normal PTZ]+bilirubin)
• The best predictor of prognosis in alcoholic chronic liver disease is the degree of injury on liver biopsy and the stage of fibrosis.
Treatment:
• Cessation of alcohol intake is the most important treatment step.
• Corticosteroids are given to reduce short-term mortality in patients with severe alcoholic hepatitis. Pentoxifylline is an alternative to steroids.