This document provides an overview of alcoholic liver disease (ALD) in multiple parts. It begins by discussing how alcohol is metabolized in the liver and can cause liver dysfunction by damaging hepatocytes and producing toxic byproducts. The major manifestations of ALD are then described, including jaundice, coagulopathy, and encephalopathy, which result from impaired bilirubin metabolism, clotting factor synthesis, and other liver functions. The document outlines the spectrum of ALD from fatty liver to alcoholic hepatitis to cirrhosis. Diagnosis involves assessing alcohol use history and liver enzymes/function. The characteristics of fatty liver, alcoholic hepatitis, and cirrhosis are summarized.

1. Alcoholic Liver disease: an
introduction part 2
Pratap Sagar Tiwari, Lecturer, NGMC

2. Our Journey
Alcohol & Liver
Clinical Features
Making a diagnosis
Complications
Portal Hypertension
Hepatic encephalopathy
Management

3. Alcoholic liver disease
liver dysfunction because of Alcohol
Liver
Dysfunction
What
then ?
Because of
Alcohol
How ?

4. Functions that are affected..
• Detoxification
• Bilirubin
metabolism
• Clotting factors
Synthesis of
• Thrombopoietin
• Albumin
• Angiotensinogen
CHO /protein/ lipid
metabolism
Storage of Vitamins

5. Manifestations…
Jaundice
• Bilirubin
metabolism
• Clotting
factors
• Detoxification
Coagulopathy
Encephalopathy

6. Definition
• Any pathological conditions of liver as a result
of chronic and excessive alcohol consumption
leading to a spectrum of conditions from
ranging from asymptomatic fatty liver to
alcoholic hepatitis to end-stage liver failure
with
jaundice,
coagulopathy,
and
encephalopathy.

7. Metabolism of Alcohol
Ethanol
Citric Acid cycle
Oxidized
Acetaldehyde
alcohol dehydrogenase IB (ADH)
CYP2E1
Catalase
Tetrahydroisoquinolines
CO2/ATP
(TIQs)
Acetaldehyde
dehydrogenase
enters
Acetyl-coenzyme A synthetase
acetyl-CoA
Acetic acid
Note: Disulfiram inhibits Acetaldehyde dehydrogenase

8. Alcohol & Acetaldehyde
If not metabolized,releases free radicals
Damage to embryonic neural crest cells = birth defects
Alcohol forms “Adducts” that activate immune system  cell injury
Cytochrome CYP2E1 metabolizes ethanol to Acetate, releasing oxygen free radical 
radical induced injury
Alcohol ↑ gut permeability ↑ endotoxin  Kupffer cells activation  TNF a, IL6
Inflamation
Alcoholic liver Disease
Free Radicals:eg superoxide ( O2- ),hydrogen peroxide (H2O2), peroxynitrite
Antioxidants are Vit A,C,E, Superoxide dismutase, beta carotene, glutathione

9. • Beginning of Part 2………

10. ALD: Spectrum
• The pathology of alcoholic liver disease
consists of three major lesions, with the injury
rarely existing in a pure form:
(1) fatty liver,
(2) alcoholic hepatitis,
(3) cirrhosis.

11. Diagnosis of alcoholic liver disease
1. A thorough history of alcohol use.
2. CAGE:screening method for alcohol abuse or
dependency.
3. A detailed P/E should be done, searching for
signs of CLD and staging its severity.
4. A liver chemistry profile (including serum
albumin, bilirubin and transaminases [AST/ALT]).
CBC & PT/INR.
5. It may be necessary to perform a liver biopsy in
patients with suspected alcoholic liver disease
when the diagnosis is unclear .

12. CAGE Questionaaire
• Have you felt the need to Cut down drinking?
• Have you ever felt Annoyed by criticism of
drinking?
• Have you had Guilty feelings about drinking?
• Do you ever take a morning Eye opener ?

13. ALD:Fatty liver
• Fatty liver, also known as fatty liver disease (FLD), is a
reversible
condition
wherein
large vacuoles of triglyceride fat accumulate in liver
cells via the process of steatosis (i.e., abnormal
retention of lipids within a cell).
• AFL(steatosis) is rarely diagnosed clinically because
most patients are asymptomatic.
• The only complaint may be mild, tender
hepatomegaly.
• DX: in pt with alcohol abuse/dependent with fatty
changes in imaging and excluding other causes. LFT
may be normal/mild abnormal.

14. Microvesicular fat
Macrovesicular fat
Alcoholic foamy degeneration
Acute fatty liver of pregnancy
Reye's syndrome
Valproic acid
Tetracycline
Alcohol
Malnutrition
Obesity
Diabetes mellitus
Corticosteroids
Total parenteral nutrition

15. ALD: Alcoholic hepatitis
• The characteristic clinical features of alcoholic
hepatitis are
fever, hepatomegaly, jaundice, and anorexia.
• Patients can also present with right upper
quadrant/epigastric pain, hepatic
encephalopathy, and bleeding.

16. ALCOHOLIC CIRRHOSIS AND FIBROSIS
• The term "fibrosis" in this setting denotes the
accumulation of scar or extracellular matrix
(ECM), and is potentially reversible in the
absence of continued alcohol abuse.
• In contrast, true cirrhosis is characterized by
the presence of regenerative nodules and is
irreversible even in the absence of further
alcohol ingestion.

17. Acute liver failure
• Acute liver failure is an uncommon condition
in which the rapid deterioration of liver
function results in coagulopathy and
alteration
in
the
mental
status
(encephalopathy) of a previously healthy
individual.

18. Liver failure: definitions
• Acute liver failure is a broad term that encompasses
both fulminant hepatic failure and subfulminant
hepatic failure (or late-onset hepatic failure).
• Fulminant hepatic failure is generally used to describe
the development of encephalopathy within 8 weeks of
the onset of symptoms in a patient with a previously
healthy liver.
• Subfulminant hepatic failure is reserved for patients
with liver disease for up to 26 weeks before the
development of hepatic encephalopathy.

19. Next Part :
• Clinical features………….

20. • End of Part two………….