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.
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 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 withMicronodular 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.
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.)