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Alcoholic liver disease.


Fermented beverages and associated liver disease date back almost 12,000 years. The American College of Gastroenterology and the American Association for the Study of Liver Diseases recently produced a practice guideline on this common, chronic impairment.


Nearly two-thirds of Americans drink some form of alcohol, and nearly 7.5% of the adult population meets criteria for alcohol abuse and/or alcohol dependence. Across societies, for every 1 liter increase in per capita annual consumption of alcohol, there is a 14% increased incidence of cirrhosis in men and an 8% increase in women. Alcohol is responsible for more than 40% of deaths from liver disease.

Histologic injury from alcohol is usually staged into three groups: fatty liver (steatosis), alcoholic hepatitis, and chronic hepatitis with fibrosis or cirrhosis. More advanced injury is associated with Mallory's hyaline and megamitochondria.

A standard alcoholic drink contains 12 g of alcohol. Of those who drink 60 g/day, 90% develop fatty liver. Fibrotic changes occur in 40%-60% of drinkers who consume 40-80 g/day over 25 years. In general, the risk of cirrhosis is increased with long-term ingestion of more than 60 g/day in men and 20 g/day in women. African Americans and Hispanic men have higher rates of cirrhosis than do whites with similar ingestion patterns.

Fatty liver is usually asymptomatic and reversible by 4-6 weeks of abstinence. Nevertheless, about 10% of these drinkers who achieve abstinence will progress to fibrosis.

Patients who develop alcoholic hepatitis have a worse prognosis. Symptomatic disease is often associated with progressive fibrosis leading to cirrhosis. Abstinence may or may not affect the long-term histology and persistence of alcoholic hepatitis.


"Safe" ingestion of alcohol is considered to be less than 170 g/week for men and 110 g/'week for women.

The medical community has underrecognized problem drinkers, and these patients often minimize their behavior. Patterns of medical visits may suggest alcohol overconsumption as a unifying background diagnosis. Structured screening tools such as the CAGE, MAST, and AUDIT questionnaires can be helpful in identifying patients who would benefit from counseling and intervention.

Physical examination in patients other than those with advanced cirrhosis is usually nonspecific. Palpation of the liver can be normal and is not reliable for estimating liver volume. Comorbid conditions that coexist with alcoholic liver disease include cardiomyopathy, muscle wasting, neuropathy, and pancreatic insufficiency.

There are no standard laboratory tests to identify patients with problem drinking. Many patients have elevated gamma-glutamyl-transpeptidase (GGT) and macrocytosis An AST/ALT ratio over 3 is highly associated with alcoholic liver disease.

Liver biopsy is not necessary for managing alcoholic liver disease, although approximately 20% of patients have a secondary or comorbid hepatic diagnosis. Biopsy should be considered if the results could alter subsequent therapy.

The Maddrey discriminant function (MDF) can identify patients at high risk of short-term mortality. The MDF is equal to 4.6 (patient's prothrombin time--control time)/total bilirubin (mg/dL) Patients with scroes higher than 32 can have 1-month mortality over 30%.

Serial calculation of the Model for End-Stage Liver Disease (MELD) scores can also be useful to stage and assess risk in patients with advanced liver disease.

Patients with alcoholic hepatitis benefit from strict abstinence and nutritional support. Patients with severe hepatitis (MDF over 32) might benefit from a moth of 40 mg/day of prednisolone or 400 mg 3 times a day of pentoxifylline. Colchicine or propylthiouracil should not be used in the treatment of alcoholic liver disease.

Abstinence can result in significant improvement after 3 months. It improves histology, reduces portal pressure, and improves survival of patients throughout the spectrum of liver injury. Patients with chronic hepatitis C should pursue complete abstinence, as persistent alcohol abuse has been noted to increase the risk of cirrhosis 30-fold.

More than two-thirds of patients with consumption issues relapse in the first year of abstinence. Disulfiram is poorly tolerated and no longer a first-line agent to support abstinence. Naltrexone is useful for short-term craving for alcohol, but is potentially hepatotoxic itself. Acamprosate has been effective in helping patients maintain abstinence. These drugs should be used in combination with counseling for effective interventions.


O'Shea R.S., et al. Alcoholic liver disease. Hepatology 2010;51:307-28.

DR. GOLDEN (left) is professor of medicine and public health and DR. HOPKINS is program director for the internal medicine /pediatrics combined residency program at the University of Arkansas, Little Rock. Write to Dr. Golden and Dr. Hopkins at our editorial offices or imnews@elsevier com.

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Author:Golden, William E.; Hopkins, Robert H.
Publication:Internal Medicine News
Article Type:Clinical report
Geographic Code:1USA
Date:Mar 1, 2010
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