fbpx

Alcoholic Liver Disease

Updated : September 5, 2023





Background

Alcoholic liver disease (ALD) is a chronic disease that occurs due to excessive alcohol consumption. It is one of the most common liver diseases in the world and a major cause of liver-related morbidity and mortality. ALD develops in individuals who consume large amounts of alcohol for an extended period, leading to damage to the liver tissue.

The liver plays a crucial role in the body’s metabolism, including breaking down alcohol. However, excessive alcohol consumption overloads the liver, leading to liver damage. ALD encompasses a range of liver conditions, including fatty liver, alcoholic hepatitis, and cirrhosis. These conditions can occur separately or together, with varying degrees of severity.

Epidemiology

Alcohol is one of the most commonly abused substances worldwide, including in the United States, and is responsible for various adverse health outcomes, including liver disease. According to data from the National Institute on Alcohol Abuse and Alcoholism, 61 % of American adults reported consuming alcohol in the past year. Among these individuals, 10 to 12 % were classified as heavy drinkers.

Alcoholic liver disease is a serious consequence of long-term alcohol abuse, and it is more prevalent in some European countries than in the United States. This disease can develop in individuals who consume as little as 30 to 50 grams of alcohol daily for over five years. Steatosis, or the buildup of fat in the liver, can occur in up to 90% of patients who drink over 60 grams of alcohol daily.

Anatomy

Pathophysiology

1. Direct toxic effects of alcohol: Ethanol, the primary component of alcoholic beverages, is metabolized in the liver by two major enzymes: alcohol dehydrogenase (ADH) and cytochrome P450 2E1 (CYP2E1). Ethanol metabolism generates acetaldehyde, a highly reactive and toxic intermediate that can damage liver cells directly by forming adducts with cellular proteins and DNA. Acetaldehyde can also interfere with the transport of lipids and other nutrients across the liver cell membrane, leading to cellular dysfunction and death.

2. Oxidative stress and inflammation: Alcohol metabolism generates reactive oxygen species (ROS) that can induce oxidative stress in liver cells by damaging cellular proteins, lipids, and DNA. ROS can also activate pro-inflammatory pathways by stimulating the production of cytokines, chemokines, and adhesion molecules. Chronic alcohol consumption can lead to persistent oxidative stress and inflammation, promoting liver injury and fibrosis.

3. Disruption of lipid metabolism: Alcohol consumption can disrupt lipid metabolism by altering the expression and activity of several key enzymes and transcription factors involved in lipid synthesis, uptake, and transport. This can lead to the accumulation of triglycerides and other lipids in liver cells, causing fatty liver disease. Fatty liver can progress to steatohepatitis, a more severe form of ALD characterized by inflammation and liver cell damage.

4. Gut-liver axis dysfunction: Chronic alcohol consumption can alter the composition and function of the gut microbiome, leading to dysbiosis and increased gut permeability. This allows the translocation of bacterial products such as lipopolysaccharides (LPS) into the liver, triggering an immune response and promoting liver inflammation and fibrosis.

Etiology

Alcoholic liver disease is influenced by various factors, such as genetic, metabolic, environmental, and immunological factors. The liver can tolerate moderate alcohol consumption, but as the consumption of alcohol increases, it disrupts the liver’s metabolic functioning. Initially, this leads to fat accumulation in the liver, and if alcohol consumption persists, it may progress to alcoholic hepatitis.

In the advanced stages of alcoholic liver disease, liver cells may be severely damaged, leading to alcoholic cirrhosis. The quantity and duration of alcohol consumption primarily determines the risk of developing liver disease. The type of alcoholic beverage consumed has a minor role in this process. Women are more vulnerable to developing alcoholic liver disease than men.

Other risk factors include a high-fat diet, obesity, and concurrent hepatitis C infection, associated with a younger age of onset, more advanced histological damage, and decreased survival. Additionally, alcoholic liver cirrhosis has been linked to the presence of the patatin-like phospholipase domain-containing protein 3 (PNPLAP3).

Genetics

Prognostic Factors

The prognosis for alcoholic liver disease is generally poor if the individual continues to drink alcohol. However, if the individual quits alcohol and receives appropriate medical treatment, the liver may be able to heal itself, and the prognosis can improve. Individuals with alcoholic liver disease need to seek medical treatment and support to quit drinking and manage their condition.

Clinical History

Clinical History

When assessing a patient for possible alcohol-related liver injury, it is essential to obtain their drinking history, including the frequency and duration of alcohol consumption. Additionally, personal and psychosocial factors play a significant role, as excessive alcohol intake is linked to depression and other psychological disorders.

Inquiring about the patient’s diet, caloric intake, alcohol consumption, malnutrition risk factors, and chronic liver disease risk factors is also essential. Symptoms that may indicate alcohol-related liver injury include nausea, abdominal discomfort, vomiting, loss of appetite, weight changes, yellowing of the eyes, increased thirst, weakness, confusion, mood swings, disrupted sleep patterns, and fainting.

Physical Examination

Physical History

Alcoholic hepatitis is a severe liver condition that typically affects individuals between the ages of 40 and 50 with a history of heavy alcohol use. The primary symptom of this condition is the rapid onset of jaundice, which is characterized by yellowing of the skin and eyes. Other common symptoms include fever, tender hepatomegaly, and ascites.

Patients with severe alcoholic hepatitis may also experience encephalopathy. Additionally, physical examination of patients with alcoholic hepatitis often reveals several characteristic signs and symptoms, including agitation, disoriented to place or time due to withdrawal, malnourished, pale appearance, spider telangiectasias, decreased libido, Dupuytren contractures, parotid, testicular atrophy, and lacrimal gland enlargement.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnoses

Reye Syndrome

Emphysema

Ascending Cholangitis

Fulminant Wilson Disease

Cryptogenic Liver Disease

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The management of alcohol-related liver disease is dependent on the extent of liver damage. Individuals who have a history of chronic alcoholism are at a higher risk of developing hepatotoxicity from acetaminophen; therefore, acetaminophen dosing should not exceed 2000 mg per day. A liver transplant is the definitive treatment option in cases where liver damage is irreversible.

However, liver transplantation is only offered to individuals who have demonstrated a commitment to abstaining from alcohol use.
Abstinence and adequate nutritional support remain the cornerstone of managing individuals with alcoholic liver disease. The support required for achieving abstinence can be individualized and enhanced with the assistance of an addiction specialist.

For individuals with alcoholic hepatitis complicated by hepatic encephalopathy, prednisolone 40 mg/day for a month may be considered. Prednisolone is favored over prednisone since it does not require metabolism in the liver for its therapeutic efficacy. In cases where oral administration of prednisolone is not possible, methylprednisolone may be administered.

However, if a patient fails to respond to steroids within one week of treatment, as indicated by a Lille score greater than 0.45, then steroids should be discontinued. There are certain contraindications to the use of steroids, including severe pancreatitis, active gastrointestinal bleeding, uncontrolled diabetes, renal failure, or active infection.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

prednisolone 

Off-label:

40

mg

Orally 

every day

28

days

; then taper off for 2 to 4 weeks



sAMe 

Oral: take 1200 to 1600 mg daily dose and only up to 24 months
Intravenous: administer 200 to 2000 mg dose daily for 15 to 30 days
Intramuscular: administer 200 mg daily dose for one month



milk thistle 


Indicated for Alcoholic liver disease, gallbladder problems, jaundice
140 mg of silymarin extract orally three times in a day
Chronic Hepatitis
240 mg of Silibinin active constituent orally two times in a day
Hepatic Cirrhosis
420 mg of 70-80% silymarin extract orally every day
Dyspepsia
1 ml of liquid orally three times in a day
Diabetes
200 mg of silymarin extract orally three times in a day in fusing with conventional therapy



 
 

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK546632/

Alcoholic Liver Disease

Updated : September 5, 2023




Alcoholic liver disease (ALD) is a chronic disease that occurs due to excessive alcohol consumption. It is one of the most common liver diseases in the world and a major cause of liver-related morbidity and mortality. ALD develops in individuals who consume large amounts of alcohol for an extended period, leading to damage to the liver tissue.

The liver plays a crucial role in the body’s metabolism, including breaking down alcohol. However, excessive alcohol consumption overloads the liver, leading to liver damage. ALD encompasses a range of liver conditions, including fatty liver, alcoholic hepatitis, and cirrhosis. These conditions can occur separately or together, with varying degrees of severity.

Alcohol is one of the most commonly abused substances worldwide, including in the United States, and is responsible for various adverse health outcomes, including liver disease. According to data from the National Institute on Alcohol Abuse and Alcoholism, 61 % of American adults reported consuming alcohol in the past year. Among these individuals, 10 to 12 % were classified as heavy drinkers.

Alcoholic liver disease is a serious consequence of long-term alcohol abuse, and it is more prevalent in some European countries than in the United States. This disease can develop in individuals who consume as little as 30 to 50 grams of alcohol daily for over five years. Steatosis, or the buildup of fat in the liver, can occur in up to 90% of patients who drink over 60 grams of alcohol daily.

1. Direct toxic effects of alcohol: Ethanol, the primary component of alcoholic beverages, is metabolized in the liver by two major enzymes: alcohol dehydrogenase (ADH) and cytochrome P450 2E1 (CYP2E1). Ethanol metabolism generates acetaldehyde, a highly reactive and toxic intermediate that can damage liver cells directly by forming adducts with cellular proteins and DNA. Acetaldehyde can also interfere with the transport of lipids and other nutrients across the liver cell membrane, leading to cellular dysfunction and death.

2. Oxidative stress and inflammation: Alcohol metabolism generates reactive oxygen species (ROS) that can induce oxidative stress in liver cells by damaging cellular proteins, lipids, and DNA. ROS can also activate pro-inflammatory pathways by stimulating the production of cytokines, chemokines, and adhesion molecules. Chronic alcohol consumption can lead to persistent oxidative stress and inflammation, promoting liver injury and fibrosis.

3. Disruption of lipid metabolism: Alcohol consumption can disrupt lipid metabolism by altering the expression and activity of several key enzymes and transcription factors involved in lipid synthesis, uptake, and transport. This can lead to the accumulation of triglycerides and other lipids in liver cells, causing fatty liver disease. Fatty liver can progress to steatohepatitis, a more severe form of ALD characterized by inflammation and liver cell damage.

4. Gut-liver axis dysfunction: Chronic alcohol consumption can alter the composition and function of the gut microbiome, leading to dysbiosis and increased gut permeability. This allows the translocation of bacterial products such as lipopolysaccharides (LPS) into the liver, triggering an immune response and promoting liver inflammation and fibrosis.

Alcoholic liver disease is influenced by various factors, such as genetic, metabolic, environmental, and immunological factors. The liver can tolerate moderate alcohol consumption, but as the consumption of alcohol increases, it disrupts the liver’s metabolic functioning. Initially, this leads to fat accumulation in the liver, and if alcohol consumption persists, it may progress to alcoholic hepatitis.

In the advanced stages of alcoholic liver disease, liver cells may be severely damaged, leading to alcoholic cirrhosis. The quantity and duration of alcohol consumption primarily determines the risk of developing liver disease. The type of alcoholic beverage consumed has a minor role in this process. Women are more vulnerable to developing alcoholic liver disease than men.

Other risk factors include a high-fat diet, obesity, and concurrent hepatitis C infection, associated with a younger age of onset, more advanced histological damage, and decreased survival. Additionally, alcoholic liver cirrhosis has been linked to the presence of the patatin-like phospholipase domain-containing protein 3 (PNPLAP3).

The prognosis for alcoholic liver disease is generally poor if the individual continues to drink alcohol. However, if the individual quits alcohol and receives appropriate medical treatment, the liver may be able to heal itself, and the prognosis can improve. Individuals with alcoholic liver disease need to seek medical treatment and support to quit drinking and manage their condition.

Clinical History

When assessing a patient for possible alcohol-related liver injury, it is essential to obtain their drinking history, including the frequency and duration of alcohol consumption. Additionally, personal and psychosocial factors play a significant role, as excessive alcohol intake is linked to depression and other psychological disorders.

Inquiring about the patient’s diet, caloric intake, alcohol consumption, malnutrition risk factors, and chronic liver disease risk factors is also essential. Symptoms that may indicate alcohol-related liver injury include nausea, abdominal discomfort, vomiting, loss of appetite, weight changes, yellowing of the eyes, increased thirst, weakness, confusion, mood swings, disrupted sleep patterns, and fainting.

Physical History

Alcoholic hepatitis is a severe liver condition that typically affects individuals between the ages of 40 and 50 with a history of heavy alcohol use. The primary symptom of this condition is the rapid onset of jaundice, which is characterized by yellowing of the skin and eyes. Other common symptoms include fever, tender hepatomegaly, and ascites.

Patients with severe alcoholic hepatitis may also experience encephalopathy. Additionally, physical examination of patients with alcoholic hepatitis often reveals several characteristic signs and symptoms, including agitation, disoriented to place or time due to withdrawal, malnourished, pale appearance, spider telangiectasias, decreased libido, Dupuytren contractures, parotid, testicular atrophy, and lacrimal gland enlargement.

Differential Diagnoses

Reye Syndrome

Emphysema

Ascending Cholangitis

Fulminant Wilson Disease

Cryptogenic Liver Disease

The management of alcohol-related liver disease is dependent on the extent of liver damage. Individuals who have a history of chronic alcoholism are at a higher risk of developing hepatotoxicity from acetaminophen; therefore, acetaminophen dosing should not exceed 2000 mg per day. A liver transplant is the definitive treatment option in cases where liver damage is irreversible.

However, liver transplantation is only offered to individuals who have demonstrated a commitment to abstaining from alcohol use.
Abstinence and adequate nutritional support remain the cornerstone of managing individuals with alcoholic liver disease. The support required for achieving abstinence can be individualized and enhanced with the assistance of an addiction specialist.

For individuals with alcoholic hepatitis complicated by hepatic encephalopathy, prednisolone 40 mg/day for a month may be considered. Prednisolone is favored over prednisone since it does not require metabolism in the liver for its therapeutic efficacy. In cases where oral administration of prednisolone is not possible, methylprednisolone may be administered.

However, if a patient fails to respond to steroids within one week of treatment, as indicated by a Lille score greater than 0.45, then steroids should be discontinued. There are certain contraindications to the use of steroids, including severe pancreatitis, active gastrointestinal bleeding, uncontrolled diabetes, renal failure, or active infection.

prednisolone 

Off-label:

40

mg

Orally 

every day

28

days

; then taper off for 2 to 4 weeks



sAMe 

Oral: take 1200 to 1600 mg daily dose and only up to 24 months
Intravenous: administer 200 to 2000 mg dose daily for 15 to 30 days
Intramuscular: administer 200 mg daily dose for one month



milk thistle 


Indicated for Alcoholic liver disease, gallbladder problems, jaundice
140 mg of silymarin extract orally three times in a day
Chronic Hepatitis
240 mg of Silibinin active constituent orally two times in a day
Hepatic Cirrhosis
420 mg of 70-80% silymarin extract orally every day
Dyspepsia
1 ml of liquid orally three times in a day
Diabetes
200 mg of silymarin extract orally three times in a day in fusing with conventional therapy



https://www.ncbi.nlm.nih.gov/books/NBK546632/