Alcoholic Liver Disease
By Howard J. Worman, M. D.
Alcohol abuse is a leading cause of morbidity and mortality throughout
the world. It is estimated that in the United States as many as 10 % of
men and 3 % of women may suffer from persistent problems related to the
use of alcohol. The Fourth Edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) published by the American Psychiatric Association
divides alcohol use disorders into "alcohol dependence" and "alcohol abuse."
Alcohol dependence is indicated by evidence of tolerance and/or symptoms
of withdrawal such as delirium tremens (DTs) or alcohol withdrawal seizures
(rum fits) upon cessation of drinking. Alcohol abuse is characterized
by recurrent performance problems at school or on the job that result
either from the after effects of drinking alcohol or from intoxication
on the job or at school. In addition, patients with alcohol abuse disorders
may use alcohol in physically adverse circumstances (e.g. while driving)
and may miss work or school or neglect child care or household responsibilities
because of alcohol use. Legal difficulties related to alcohol use are
also common. Patients with alcohol abuse disorders often continue to consume
alcohol despite the knowledge that continued consumption poses significant
social or interpersonal problems for them. People with alcohol use disorders
often consume alcohol despite knowing that they suffer from alcohol-related
medical problems such as liver disease.
Alcohol affects many organ systems of the body, but perhaps most notably
affected are the central nervous system and the liver. Almost all ingested
alcohol is metabolized in the liver and excessive alcohol use can lead
to acute and chronic liver disease. Liver cirrhosis resulting from alcohol
abuse is one of the ten leading causes of death in the United States.
From data obtained in autopsy studies, it appears that between 10 % and
15 % of alcoholics have cirrhosis at the time of death. It is unknown
why some alcoholics develop liver disease while others do not. One possibility
is that there are genetic factors that predispose some alcoholics to liver
disease. Some data also suggest that co-factors such as chronic infection
with hepatitis C virus may increase the risk of the development of cirrhosis
in an alcoholic. In general, women who drink an equal amount of alcohol
are at higher risk than men for the development of liver disease, possibly
because of decreased metabolism of alcohol in the stomach prior to absorption.
REMEMBER, LIVER DISEASE IS NOT THE ONLY LIFE-THREATENING COMPLICATION
OF ALCOHOL USE DISORDERS. ALL ALCOHOLICS MUST ABSTAIN FROM DRINKING AS
NUMEROUS OTHER ALCOHOL-RELATED MEDICAL, SOCIAL AND PSYCHOLOGICAL PROBLEMS
CAN LEAD TO MORBIDITY AND MORTALITY.
Alcohol abuse generally leads to three pathologically distinct liver
diseases. In clinical practice, any or all of these three conditions can
occur together, at the same time, in the same patient. These three conditions
are:
- Fatty Liver (Steatosis)
- Alcohol abuse can lead to the accumulation of fat within hepatocytes,
the predominant cell type in the liver. A similar condition can also
be seen in some obese people who are not alcohol abusers. Fatty liver
is reversible if the patient stops drinking, however, fatty liver can
lead to steatohepatitis. Steatohepatitis is fatty liver accompanied
by inflammation and this condition can lead to scarring of the liver
and cirrhosis. Click to see a microscopic section of a Normal Liver Lobule
and an example of Fatty Liver
in an alcoholic.
- Hepatitis
- Alcohol can cause acute and chronic hepatitis. The patient who presents
with alcoholic hepatitis is usually a chronic drinker with a recent
episode of exceptionally heavy consumption. Other presentations are
also possible. Alcoholic hepatitis can range from a mild hepatitis,
with abnormal laboratory tests being the only indication of disease,
to severe liver dysfunction with complications such as jaundice (yellow
skin caused by bilirubin retention), hepatic encephalopathy (neurological
dysfunction caused by liver failure), ascites (fluid accumulation in
the abdomen), bleeding esophageal varices (varicose veins in the esophagus),
abnormal blood clotting and coma. Histologically, alcoholic hepatitis
has a characteristic appearance with ballooning degeneration of hepatocytes,
inflammation with neutrophils and sometimes Mallory bodies (abnormal
aggregations of cellular intermediate filament proteins). Click to see
a microscopic section of a Normal Liver Lobule. Alcoholic
hepatitis is reversible if the patient stops drinking, but it usually
takes several months to resolve. Alcoholic hepatitis can lead to liver
scarring and cirrhosis, and very frequently occurs in alcoholics who
already have cirrhosis of the liver.
- Cirrhosis
Cirrhosis is characterized anatomically by widespread nodules in the
liver combined with fibrosis. In the United States, alcohol abuse is
the leading cause of liver cirrhosis. Anatomically, alcoholic cirrhosis
is almost always micronodular (i.e. the regenerating liver nodules are
small). You can click to see a microscopic section of a liver with Micronodular
Cirrhosis & Fatty Liver and a Normal Sectionfor
comparison. Cirrhosis can result from many causes other than alcohol
such as chronic viral hepatitis, metabolic and biliary diseases. The
co-existence of another chronic liver disease in a patient who abuses
alcohol likely increases the risk of developing cirrhosis (eg. an alcoholic
with chronic viral hepatitis C). Alcoholic cirrhosis can occur in patients
who have never had evidence of alcoholic hepatitis. Cirrhosis can lead
to end-stage liver disease. Some of the complications of cirrhosis are
jaundice, ascites, edema, bleeding esophageal varices, blood coagulation
abnormalities, coma and death.
Treatment
The most important measure in the treatment of alcoholic liver disease
is to ensure the total and immediate abstinence from alcohol. This will
sometimes require admission to an in-patient medical ward for prophylactic
treatment of withdrawal symptoms such as delirium tremens and seizures.
Treatment of other associated neurological conditions may also be required.
Chronic alcohol abusers often need treatment with vitamins, especially
thiamin, to correct the deficiencies that may have resulted from chronic
alcohol abuse. Intensive medical treatment of the complications of acute
alcoholic hepatitis or cirrhosis is also sometimes necessary, as is the
treatment of concurrent infectious and/or metabolic disorders.
Once the patient is medically stable , he/she should receive on-going
treatment to ensure abstinence from alcohol. This often includes a period
of in-patient alcohol rehabilitation followed by subsequent long-term
participation in support groups such as Alcoholics Anonymous and possibly
continuous out-patient psychiatric care. Cessation of alcohol use will
reverse fatty liver and alcoholic hepatitis. Although cirrhosis is irreversible,
alcohol abusers who stop drinking will often have a good prognosis in
that progressive liver deterioration can be avoided.
(Images are part of WebPath and are copyrighted by the
Pathology Department of the University of Utah Health Sciences Center.
Link with permission of Edward C. Klatt, M. D.)
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