ALBOHOLIC LIVER DISEASE

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ALCOHOLIC LIVER
DIASEASE
Dr Nazim
NAZIMARAIN81@HOTMAIL.COM

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Incidence
 Prevalence of alcohol related disorders was 1.7 % worldwide and alcohol was
the 3rd
leading cause of death in US.
 Worldwide mortality is estimated to be 150,000 per year .
 Among heavy drinkers 90-100% will develop hepatic steatosis in 10 years.
 Only 10-35% develop steatohepatitis and 8-20% will develop cirrhosis in the
same period.
 Liver cirrhosis develops in 6-14 % of those who consume > 60-80g alcohol daily
for men and > 20g daily in women .
 Who drink >120g daily only 13.5 % will suffer serious alcohol related injury .
 Despite cessation of alcohol use only 10% will have normalization of histology
and LFTs .

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Progression in alcoholic liver disease

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Alcohol Content of Some Common Beverages
 12oz of BEER contain 12g of alcohol .
 5oz of WINE contain 12g of alcohol .
 1.5oz of HARD LIQUAR contain 12g of alcohol .
 One drink is equal to 8g in UK and 19.75g in Japan .

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Definations
 The following categories are designated by NIAA criteria :
 Moderate drinking: low risk for alcohol problems
 Men: <3 drinks per day
 Women: <2 drinks per day
 People age ≥65: < 2 drinks per day
 Heavy drinking: at risk for alcohol problems
 Women: >7 drinks per week or 3 drinks per occasion
 Men: >14 drinks per week or 4 drinks per occasion
 Binge drinking:
 Women: 4 or more drinks in a row
 Men: 5 or more drinks in a row

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Pathogenesis

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Pathogenesis
 Cofactors that potentiate the development of ALD .
 AGE
 Early age alcohol use is associated with alcoholism later in life.
 Highest rate of alcohol abuse morbidity occurs among individuals aged 45-64
years with a prevalence rate of 94.8 % per 100,000.
 GENDER
 The overall prevalence of alcohol abuse and related liver disease is higher
among man than women .
 Woman are more prone than man to alcohol related liver injury and fibrosis
progression for the same amount of the alcohol consumption .
 This may be due to different rates of alcohol metabolism lower body mass.

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Cofactors that potentiate the development of ALD .
 Ethnicity
 Susceptibility to ALD is believed to vary among different ethnic groups in U.S :
 Alcoholic cirrhosis related deaths are highest in Hispanic males.
 Prevalence among female is highest in black non Hispanic.
 Studies in U.K suggest that south asian men are more susceptible to alcohol
related liver injury than European men .
 Hepatitis C infection
 Between 14 and 36% of individuals with ALD also have Chronic hepatitis C.
 Combination of HCV and ALD accelerate the progression and severity of liver
disease .
 Increase the risk of HCC .
 Decrease the likelihood of virilogic response to interferon Alfa therapy.

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Cofactors that potentiate the development of ALD .
 Hepatitis B (HBV) infection.
 Data suggest that chronic HBV infection and alcohol consumption
increase the risk for HCC .
 Iron overload
 Both iron and alcohol generate reactive O2 species that promote lipid
peroxidation with subsequent damage to cellular integrity .
 Excessive alcohol consumption (>60g/day) in patients with
hemochromatosis is associated with :
 accelerated fibogenesis
 Inc risk for HCC and
 lower long term survival .

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Cofactors that potentiate the development of ALD .
 Medications
 Have increase risk of liver injury after ingestion of multiple or above
recommended dose of acetaminophen .
 Due to rapid depletion of glutathione stores .
 Diet and lifestyle
 Have limited data.
 Coffee may be protective in ALD and related cirrhosis .
 Some studies suggest that obesity (BMI >25kg/m2 ) for >10yrs
accelerates progression of ALD .
 Pork products have been shown to be associated with alcoholic hepatitis
and cirrhosis .

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Pathophysiology of Alcohol-Induced Liver Injury

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PATHOGENESIS OF ALCOHOLIC LIVER INJURY
 Centrilobular hypoxia
 Alcohol ingestion have demonstrated susceptibility of the hepatic
pericentral area to hypoxemia due to competitive O2 consumption by
ethanol metabolism .
 These changes mimic those induced by thyroid hormone.
 These findings have led to clinical trials of PTU in patients with ongoing
alcoholic liver injury .
 Neutrophil infiltration and activation
 One of the most characteristic pathologic hallmarks of alcoholic hepatitis
is infiltration of neutrophils,
 interleukin-8 (IL-8) and a lipid metabolite of arachidonic acid both acts as
neutrophil chemoattractants .
 Inflammatory mediators from Kupffer cells (liver macrophages) may also
have a role in ethanol-induced hepatic injury .

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PATHOGENESIS OF ALCOHOLIC LIVER INJURY
 Antigenic adduct formation
 Acetaldehyde and hydroxyethyl radicals bind covalently to proteins,
thereby forming adducts that are antigenic .
 Provoking both cell-mediated and humoral immune responses to attack
cells bearing these compounds .
 Action of injurious cytokines
 Several studies have documented increased levels of the
proinflammatory cytokines tumor necrosis factor and interleukin-6 .
 In one study, mice lacking the TNF receptor 1 gene (but not the TNF
receptor 2 gene) were protected from the development of liver disease
following ethanol ingestion .

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Alcohol Metabolism
cytosol mitochondria

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Clinical findings
 Abdominal wall collaterals (caput medusa)
 Ascites
 Cutaneous telangiectasias
 Digital clubbing
 Dupuytren's contractures
 Gynecomastia
 Jaundice
 Malnutrition
 Palmar erythema
 Peripheral neuropathy
 Splenomegaly
 Testicular atrophy

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Lab findings
Abnormality Diagnostic characteristics*
Serum AST>ALT (ratio usually >2.0, both
usually <300 IU/L, and almost never >500
IU/L) IF >500 ??
Sensitivity and specificity have not been
well studied, but may vary with the
magnitude of the ratio
Elevated serum AST
Sensitivity 50 percent
Specificity 82 percent
Elevated serum ALT
Sensitivity 35 percent
Specificity 86 percent
Elevated serum GGT
Sensitivity approximately 70 percent
Specificity approximately 60 to 80 percent
High MCV Sensitivity approximately 30 to 50 percent
Specificity approximately 85 to 90 percent
Elevated carbohydrate-deficient transferrin
Sensitivity approximately 60 to 70
percent (lower values have been reported)
Specificity approximately 80 to 90 percent

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Histopathological findings
Fat droplet
Neutophilic infiltration .
Mallory bodies

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Imaging studies
 Imaging studies do not confirm the presence of alcoholic liver
disease .
 Can be used to assess for hepatic parenchymal changes.
 Ultrasound, CT scan, and MRI can be used to diagnose fatty
change, cirrhosis, or neoplastic diseases of the liver.
 On MRI,
 specific features that are suggestive of alcoholic cirrhosis
versus cirrhosis from viral hepatitis include a
 higher volume index of the caudate lobe,
 smaller size of regenerative nodules of the liver,
 more frequent visualization of the right posterior hepatic notch .

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Imaging studies
 Hepatic phosphorus 31 magnetic resonance
spectroscopy.
 Can calculate hepatic energy metabolism and phospholipid
membrane metabolism .
 Patients with cirrhosis from alcohol have lower
phosphodiesterase to ATP ratios than patients with cirrhosis from
other causes

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ROLE OF LIVER BIOPSY
 Biopsy may be indicated in:
 Any patient with serum aminotransferases elevations that persist for >6
months, even if the patient is asymptomatic.
 Patients who have evidence of liver failure (eg, abnormal prothrombin time,
hypoalbuminemia) in addition to elevated aminotransferases. If a
coagulopathy is present, transjugular biopsy is usually safer than
percutaneous biopsy.
 Patients in whom the diagnosis of alcoholic hepatitis is uncertain based
upon clinical and laboratory findings.
 Patients who may have more than one type of liver disease (such as alcohol
and hepatitis C) in whom a liver biopsy may help determine the relative
contribution of these factors .
 Patients in whom a more detailed understanding of prognosis is desired.

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Screening for alcohol abuse
 Several screening tools exist to establish the diagnosis of
alcoholism, including the
 CAGE,
 AUDIT (Alcohol Use Disorders Identification Test).
 MAST (Michigan Alcoholism Screening Test),

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CAGE QUESTIONNAIRE
 Have you ever felt the need to Cut down on drinking?
 Have you ever felt Annoyed by criticism of your drinking?
 Have you ever had Guilty feelings about your drinking?
 Do you ever take a morning Eye opener (a drink first thing in the
morning to steady your nerves or get rid of a hangover)?
 One positive response to any CAGE question suggests the need for
closer assessment .
 A positive response to at least two questions is seen in the majority
of patients with alcoholism and to all four questions in approximately
50 percent .
 In comparison, over 80 percent of nonalcoholic subjects have a
negative response to all four questions .

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Alcohol Use Disorder Identification Test (AUDIT)
 AUDIT was designed to identify patients with recent heavy drinking in
addition to alcohol dependence;
 AUDIT focuses on identifying heavy drinkers and has a higher sensitivity
and specificity than shorter screening instruments (sensitivity 51 to 97
percent; specificity 78 to 96 percent in primary care setting)
 it performs better than the CAGE questionnaire for these purposes .
 A major limitation to the AUDIT is its length !!

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Differential diagnosis
 Nonalcoholic steatohepatitis.
 Patients history .
 ALT usually twice that of AST .
 And AST is rarely >500 in alcoholic hepatitis .
 Hemochromatosis
 Patients History
 Genetic testing may reveal HFE gene.
 Pt: with ALD may have elevated transferrin saturation & ferritin levels
similar to those seen in hemochromatosis .
 Acetaminophen toxicity
 History of drug ingestion
 AST >500 .

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Indices of prognosis
 The presence of liver failure manifested by coagulopathy, jaundice,
and/or encephalopathy is a poor prognostic indicator .
 Several predictive models have been described
 Maddrey's Discriminant function
 Model for End-Stage Liver Disease (MELD) score
 Glasgow alcoholic hepatitis score
 Lille model

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Indices of prognosis
 Maddrey's Discriminant function
Discriminant function = (4.6 x [prothrombin time - control PT]) + (serum bilirubin)
 Used for estimation of Disease severity and mortality risk .
 A value greater than 32 is associated with a high short-term mortality, and has
been used to determine the need for corticosteroids in patients with severe
alcoholic hepatitis .
 MDF > 32 associated with spontaneous survival of 50-65 % without steroids
therapy .
 MDF < 32 associated with spontaneous survival of 90 % .
 In one report, the one-month mortality in patients with values above 32 who did
not receive corticosteroids was 35 % In the absence of encephalopathy .
 approximately 45 % if encephalopathy was present .

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Indices of prognosis
 Model for End-Stage Liver Disease (MELD) score
 The score is based upon the serum bilirubin, creatinine and INR.
 Used routinely for organ allocation in the United States.
 May also predict mortality in patients hospitalized for alcoholic hepatitis .
 In one study, the MELD score had similar predictive accuracy as the
Discriminant function in predicting 30- and 90-day mortality .
 MELD score >11 have 30 days mortality and >21 has 90 days mortality
predictive accuracy .
 A MELD score of 21 had a sensitivity and specificity of 75 percent for
predicting 90-day mortality.

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Indices of prognosis
 Glasgow alcoholic hepatitis score
 A multivariate model predicting mortality in alcoholic hepatitis .
 Includes age, serum bilirubin (at day 1 and day 6 to 9), blood urea
nitrogen, prothrombin time, and peripheral white blood cell count .
 An initial validation study found it had better predictive accuracy for
mortality at 28 days than the Discriminant function .
 A benefit from corticosteroids was observed only in patients with a score
≥9.

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Indices of prognosis
 Lille model
 Proposed for predicting mortality in patients with severe alcoholic
hepatitis who have been treated with corticosteroids .
 Combines six variables
 age
 Renal insufficiency (Cr >1.3 or creatinine clearance <40)
 Albumin
 Prothrombin time
 Bilirubin and
 evolution of bilirubin at day 7 .
 Performed better than the Child-Pugh score, discriminant function, or
Glasgow score in predicting survival at six months.

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TREATMENT
 Abstinence .
 Nutrition .
 Medical therapy .
 Liver transplantation .

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Treatment
 Abstinence
 Leads to reversal of liver disease and improvement in survival .
 Less than 20 % of patients will demonstrate progression of liver
disease after abstinence .
 5 year survival improves from 34 % to 60 % for those with
decompensated liver disease .
 Patients with chronic HCV infection should abstain from any alcohol
intake due to the risk for rapid acceleration of liver disease .

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Treatment
 Nutrition
 Alcoholism is associated with nutritional deficiencies .
 Enteral as well as tube feeding found to be associated with decreased mortality .
 Continued entral nutrition support after hospitalization also improves long term
morbidity .
 Cirrhotic patients usually have protein malnutrition with decrease BCCAs.
 Dietary protein should not be restricted for fear of hepatic encephalopathy.
 During hepatic encephalopathy BCAAs may be considered .
 In patients with alcoholic hepatitis BCCAs has not been found to influence short
term or long term survival .

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Treatment
 Corticosteroids
 Only five studies have shown benefit in survival mostly in rural populations the
remaining studies have been equivocal .
 Corticosteroid therapy is beneficial in improving 30 and 60 days mortality only in
patients with severe acute alcoholic hepatitis and an MDF >32 in the absence of
acute GI bleeding, renal failure, acute infection or pancreatitis .
 2 month survival is about 80 % but up to 40 % of patients still die in 6 months.
 Significant improvement in LFTs is evident at 7 day after initiation of therapy and
may be present up to 1 year .
 Patients with a score >0.45 using lille model had a mortality rate of 76 % at 6
months.
 Prednisolone given at a dose of 40mg daily for 4 wks followed by rapid 4 wks
taper .

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 Pentoxifylline
 An inhibitor of TNF synthesis .
 Shown to decrease the risk of HRS in pateints whose MDF >32 .
 Survival benefit was related to a reduction in mortality associated with
the HRS .
 Recommended dose in 400mg thrice a day.

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 Propylthiouracil
 PTU is given in an attempt to reverse this hypermetabolic response,
thereby reducing pericentral hypoxia and cell injury.
 A Cochrane review of six trials including 710 patients with alcoholic liver
disease treated with PTU versus placebo did not reveal a benefit to PTU
treated patients on liver histology or overall mortality and liver-related
mortality .

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 Colchicine
 Effects on hepatic fibrogenesis, including the inhibition of collagen
production, enhancement of collagenase activity .
 Meta-analysis of 15 randomized trials with 1714 patients with varying
degrees of alcoholic liver disease, showed no benefit of colchicine on
liver tests, histology, or overall mortality and liver-related mortal

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 Silmyrin
 Has been used for 2000 years in Europe for treatment of liver disease .
 Believed to enhance liver regeneration and protect hapetocytes from
toxicity .
 Clinical trails have yet to demonstrate a clear benefit .

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Liver Transplantation
 Liver transplantation is the only definitive therapy .
 Alcoholic hepatitis has been considered an absolute
contraindication to liver transplantation .
 Survival after transplantation is similar for patients with ALD and non
ALD .
 Requirements for transplant listing are the same as those for other
types of liver disease except :
 For a 6 months of abstinence and psychiatric evaluation before a
patient become eligible for transplantation .
 Veldt et al. suggested that patients with liver failure resulting from
alcoholic liver disease who do not recover within the first 3 months
of abstinence are unlikely to survive.

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