Alcoholic Liver Disease Hepatitis

Results from the effects of the long term excessive consumption of alcohol on the liver

Aetiology

  • Excess alcohol
  • The onset and progression of alcoholic liver disease varies between people, suggesting that there may be a genetic predisposition to having harmful effects of alcohol on the liver

Pathophysiology

1. Alcohol related fatty liver (steatosis)

  • Fat globules begin to accumulate in the cytoplasm of hepatocytes
  • Excess alcohol intake means hepatocytes have to divert resources from metabolizing fats to metabolizing alcohol
  • Fat metabolism is altered, resulting in fat deposits in cells

2. Alcoholic hepatitis

  • Acetaldehyde (intermediate in alcohol metabolism) causes hepatocellular injury leading to inflammation
  • Mild alcoholic hepatitis is usually reversible with permanent abstinence

3. Cirrhosis

  • This is where the liver is made up of scar tissue rather than healthy liver tissue - irreversible
  • Inflammation of the liver due to alcohol results in the activation of hepatic stellate cells → HSCs increase fibrosis
  • Alcohol stimulates collagen synthesis by fibroblasts as well as fibroblast proliferation
  • Mallory’s hyaline - aggregate of filament that if found in hepatocytes indicates a risk of irreversible changes in hepatocytes that may ultimately lead to cirrhosis
    • Likely caused by the inflammation caused by acetaldehyde

Clinical presentation

Symptoms

  • Malaise
  • Nausea
  • Fever

Signs

  • Ascites
  • Hepatomegaly
  • Skin - jaundice, spider naevi, easy bruising
  • Malnutrition - red togue (iron-deficiency anaemia), muscle wasting
  • Endocrine - gynaecomastia, testicular atrophy, loss of body hair
  • Neuromuscular - tremor, encephalopathy, Wernicke-Korsakoff syndrome
  • Cardiovascular - hypertension, cardiomyopathy
  • Signs of portal hypertension - caput medusa, splenomegaly (→ thrombocytopenia)

Investigations

Bloods

  • LFTs - AST > ALT, ↑ GGT
  • Prolonged PT, ↓ albumin and ↑ bilirubin suggest end stage ALD (cirrhosis)

Ultrasound

  • May show fatty changes early on
  • Can also demonstrate changes related to cirrhosis if present

Management

  • Abstinence of alcohol, consider a detoxification regime
  • Nutritional support with vitamins (particularly thiamine) and a high protein diet
  • Steroids improve short term outcomes (over 1 month) in severe alcoholic hepatitis
  • Treat complications of cirrhosis
  • Referral for liver transplant in severe disease (must abstain from alcohol for 3 months prior to treatment)