Alcoholic liver disease

Chapter 40 ALCOHOLIC LIVER DISEASE




Alcohol remains one of the most common causes of liver disease and contributes to 1000 deaths and 64,000 hospital admissions per year in Australia. National per capita alcohol consumption correlates with mortality from alcoholic liver disease (ALD), has fallen from a peak in 1985 but has been relatively static for the last decade.



PATHOLOGY AND CLINICAL PRESENTATION


Symptoms and signs are not reliable indicators of the presence or severity of ALD. There may be no symptoms even in the presence of cirrhosis. In other cases, clinical features do allow a confident diagnosis. The clinical and pathological spectrum of alcoholic liver disease includes fatty liver, hepatitis and cirrhosis, but these commonly coexist.




Alcoholic hepatitis


Alcoholic hepatitis is defined pathologically by polymorphonuclear infiltration with hepatocyte injury (ballooning necrosis and apoptosis), accumulation of Mallory’s hyaline (derived from intermediate filaments) and variable hepatic fibrosis. It presents with anorexia, nausea and abdominal pain, with jaundice, bruising and encephalopathy in association with alcohol abuse. Hepatomegaly may be marked and associated with tenderness, splenomegaly, signs of liver failure and ascites. Systemic disturbances include fever and neutrophilic leucocytosis. The gamma-glutamyltransferase (GGT) is the predominant abnormality. The AST generally exceeds the ALT, but both are only moderately raised. Values for aspartate aminotransferase (AST) or alanine aminotransferase (ALT) above 500 U/L suggest another disorder that may coexist with ALD, most often viral hepatitis or paracetamol (acetaminophen) toxicity.


Mild cases are common and typically manifest with abnormal serum biochemistry, and hepatomegaly. Severe alcoholic hepatitis is relatively rare and carries a short-term mortality of approximately 50%. The severity of alcoholic hepatitis can be assessed using a number of simple quantitative indices (Maddrey score, MELD Score, Combined Clinical and Laboratory Index). Of these, the Maddrey Discriminant Function (MDF) is the simplest (Table 40.1).


TABLE 40.1 Using the Maddrey score to assess the severity of alcoholic hepatitis















DETECTION OF ALCOHOL ABUSE


A quantitative alcohol history should be recorded for all patients. Average daily consumption is expressed in grams of alcohol or standard drinks (each containing 10 g ethanol). Consumption is frequently underreported. In some cases, alcohol abuse may be recognised via other typical medical or psychosocial problems such as depression, neurological toxicity, abdominal pain, relationship difficulties, poor work performance, trauma and violence.


Several brief questionnaires have been validated for the detection of alcohol abuse (Table 40.2). If a screening test is positive, more detailed assessment is indicated.


TABLE 40.2 Screening questions for excessive alcohol consumption





A positive response on screening indicates the need for further assesssment


Laboratory markers such as gamma-glutamyltransferase (GGT) and mean corpuscular volume (MCV) are only moderately sensitive and specific for drinking problems in general. In ALD, the GGT level is almost invariably elevated. However, elevated levels may also be seen in other liver diseases and with some drugs (notably anticonvulsants). The MCV is generally less sensitive and less specific than GGT. Combined assessment of MCV and GGT detects 70% of the alcohol-dependent population. The carbohydrate-deficient transferrin (CDT) test may be more specific than GGT, but the test is not widely available at present and there are false positives in any form of advanced liver disease. Several other laboratory parameters may be elevated, including uric acid, triglycerides and high-density lipoprotein cholesterol. These are not adequately sensitive or specific for use as a screening test.

Mar 29, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Alcoholic liver disease
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