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1. Dr Shubham Upadhyay

2. OVERVIEW
• Introduction
• Etiopathogenesis
• Clinical Features
• Diagnosis
• Prognosis
• Treatment

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© Medi - Lectures Dr Shubham Upadhyay

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© Medi - Lectures Dr Shubham Upadhyay

5. INTRODUCTION
• Responsible for 50% of mortality from all cirrhosis
• Pathology consists 3 major lesions:
1. Fatty Liver
2. Alcoholic Hepatitis
3. Cirrhosis
• World’s 3rd largest risk factor for disease burden
• Most of the mortality fue to ALD is secondary to cirrhosis

6. ETIOLOGY & RISK FACTORS
• Most imp. risk factors- Quantity & Duration of alcohol intake
• 1 beer= 4 ounces wine = 1ounce spirit(80%) = 12 gm alcohol

8. PATHOGENESIS
• Alcohol Metabolism
• Gastric
• Hepatic
• Alcohol- Direct Hepatotoxin
• Inflammatory Cascade after metabolism of alcohol

9. PATHOGENESIS
• Alcohol Metabolism
• Gastric
• Hepatic
• Alcohol- Direct Hepatotoxin
• Inflammatory Cascade after metabolism of alcohol
• Steatosis - fatty acid synthesis, ↓ fatty acid oxidation
• Intestinal derived Endotoxin
• Lipopolysaccharide hepatic influx, intestinal microbiome dysbiosis

10. PATHOGENESIS
• Alcohol Metabolism
• Gastric
• Hepatic
• Alcohol- Direct Hepatotoxin
• Inflammatory Cascade after metabolism of alcohol
• Steatosis - fatty acid synthesis, ↓ fatty acid oxidation
• Intestinal derived Endotoxin
• Lipopolysaccharide hepatic influx, intestinal microbiome dysbiosis
• Protein aldehyde adducts, Reducing equivalents, oxidative stress
• Kupffer cell, Stellate cell activation & Collagen production
• Micronodular Cirrhosis

11. PATHOLOGY
• Fatty Liver - Initial & most common histologic response to hepatotoxic
stimuli
• Alcoholic Hepatitis
• Cirrhosis- present in 50% of patients with biopsy proven alcoholic
hepatitis

12. CLINICAL FEATURES
• Fatty Liver
• Usually Asymptomatic
• Rt. hypochondrial pain, Nausea, Jaundice
• Alcoholic Hepatitis
• Wide spectrum
• Portal HTN, ascites, variceal bleeding can occur

13. CLINICAL FEATURES
• Fatty Liver
• Usually Asymptomatic
• Rt. hypochondrial pain, Nausea, Jaundice
• Alcoholic Hepatitis
• Wide spectrum
• Portal HTN, ascites, variceal bleeding can occur
• Cirrhosis
• Non specific symptoms
• Ascites, Edema, UGI bleed, jaundice, encephalopathy
• Physical Examiination
• Icterus, Palmar erythema, spider angiomas, parotid enlargement, clubbing, ms wasting
• Male vs Females
• Palpations- Hepatomegaly, splenomegaly with firm, nodular edge of liver
• End stages- Shunken Liver

14. LABORATORY FEATURES
• Fatty Liver
• Non specific elevtaion of AST, ALT, GGTP
• Hypertriglyceridemia, Hyperbilirubinemia
• USG- Fatty infiltration
• Alcoholic Hepatitis
• AST, ALT elevated 2 to 7 folds , usually <400 IV with AST:ALT ratio >1
• Modest elevation of ALP
• Advanced disease- Hypoalbuminea, Coagulopathy
• USG- Fatty Infiltration. Presence of PV flow reversal, ascites, intraabdominal
venous collaterals indicates serious liver injury

16. • Cirrhosis
• Early Compensated- Normal lab values
• Anemia
• Thrombocytopenia
• S. Bilirubin
• Prothrombin Time
• s. Na+
• AST:ALT ratio: 2:1
• USG: Shunken, fibrosed liver

17. PROGNOSIS
• Critically ill patients with alcoholic hepatitis
• Severe alcoholic hepatitis
• Coaguopathy
• Anemia
• Hypoalbuminemia
• Hyperbilirubinemia
• Renal Failure
• Ascites
• Discriminant Function
• MELD score
• Poor Prognosis - Ascites, variceal hmg, encephalopathy, heptaorenal
syndrome
• 5 yr survival in cirrhotics who continue to drink?

18. TREATMENT
• Complete Abstinence from Alcohol
• Glucocorticoids
• Prednisolone
• DF>32 or MELD>20
• C/I
• Pentoxiphylline
• Avoidance of concomitant hepatotoxic drugs
• Liver Transplantation