Risk of developing alcoholic liver disease
All patients should be advised of the health risks of drinking as outlined in Canada’s Guidance on Alcohol and Health (2023). People who drink heavily every day are at greater risk of developing cirrhosis than people who binge drink. One study found that men with cirrhosis consumed an average of 6.2 drinks per day over 20 years, and women consumed an average of 4.4 drinks per day over nine years (Stokkeland et al., 2008).
Patients with hepatitis C should be advised to abstain from alcohol because they are at substantially greater risk of cirrhosis, even if they drink moderately.
The spectrum of alcoholic liver disease
Hepatocytes can regenerate following a toxic insult, and the liver can function even if most of it has been replaced with scar tissue. This explains why the early stages of alcoholic liver disease are reversible and asymptomatic, and even patients with extensive cirrhosis can often live normal lives if they abstain from alcohol.
Alcoholic fatty liver disease
With alcoholic fatty liver disease, patients:
- Are usually asymptomatic.
- Have an enlarged, firm, mildly tender liver.
- Have mildly elevated liver enzymes.
- Will often resolve the disease with abstinence.
Alcoholic hepatitis
Alcoholic hepatitis can be mild, moderate, or severe.
- Mild: Patients are often asymptomatic, with elevation of liver enzymes to two to three times the upper limit of normal.
- Moderate: Patients present with typical symptoms of hepatitis (fatigue, anorexia, weight loss, vomiting, jaundice, right upper quadrant pain).
- Severe: Patients present with fever, jaundice, ascites, hyperdynamic circulation and encephalopathy.
- Patients with moderate or severe alcoholic hepatitis should go to the emergency department for investigations and management. Those with marked encephalopathy have a mortality rate of up to 50 per cent.
- Indicators of a poor prognosis include:
- Low serum albumin
- Elevated international
- Normalized ratio (INR)
- Elevated serum bilirubin
- Signs of encephalopathy.
Cirrhosis
Patients with cirrhosis display the following characteristics:
- Permanent destruction of the liver architecture and, thus, function; liver enzymes may be raised.
- Tests of liver function that are abnormal (i.e., low albumin, raised INR).
- Hepatomegaly or a small, shrunken right lobe and hypertrophied left lobe (palpable in epigastrium).
- Stigmata of chronic liver disease may be present (gynecomastia, testicular atrophy, spider nevi, palmar erythema, splenomegaly, ascites).
- Complications include encephalopathy, ascites, bleeding varices, portal hypertension and subacute bacterial peritonitis.
Cirrhosis with hepatitis
When patients have cirrhosis and hepatitis, they:
- Sometimes develop a superimposed alcoholic hepatitis with elevation of liver enzymes; if severe, this can precipitate liver failure.
- Will have accelerated progression of cirrhosis if the hepatitis is chronic or recurrent.
Laboratory tests and diagnostic imaging for alcoholic liver disease
Gamma-glutamyl transferase (GGT), mean cell volume (MCV) and platelets
- Elevated GGT, macrocytosis and mild thrombocytopenia suggest continued alcohol use, but not necessarily chronic liver disease.
- Macrocytosis (with target cells) can occur in cirrhosis.
- Persistent or severe thrombocytopenia suggests splenomegaly.
Aspartate aminotransferase (AST), alanine aminotransferase (ALT)
- In alcoholic hepatitis, AST is more than ALT (often in a 2:1 ratio).
- In viral hepatitis, ALT is more than AST.
- AST of more than 100 implies moderate to severe alcoholic liver disease.
Hepatitis B and C
- The presence of viral hepatitis (hepatitis B or C) should be ruled out if liver enzymes are elevated.
- People who drink heavily have a higher prevalence of viral hepatitis.
- Chronic viral hepatitis worsens the prognosis of alcoholic liver disease.
Liver function tests: International normalized ratio (INR), albumin, bilirubin
- Increased INR or bilirubin, or decreased albumin, indicates liver dysfunction caused by cirrhosis or severe alcoholic hepatitis.
Blood alcohol concentration (BAC)
- Lab measurement of serum BAC can be used in the emergency department to follow the metabolism of alcohol and in the office to confirm intoxication or to assess alcohol dependence.
- A patient with a high alcohol tolerance from heavy use may not appear inebriated, but may have a high BAC.
Ultrasound
- Commonly identifies fatty liver.
- May be normal, even in cirrhosis.
- Nodularity indicates cirrhosis.
- Splenomegaly suggests portal hypertension due to cirrhosis.
- Ultrasound can be used to detect ascites and to screen for hepatomas.
Endoscopy
- Detects varices and measures portal pressures in patients with cirrhosis.
- Also detects gastritis, esophagitis and ulcers.
Liver biopsy
- Rules out other causes of liver disease.
- Determines the extent of cirrhosis prior to long-term treatment.
In Alcohol Use:
- Alcohol Use: Home
- Screening
- Assessment
- Treatment
- Managing alcohol use disorders
- Alcoholics Anonymous
- Medications for alcohol use disorders
- Managing alcohol withdrawal
- Alcoholic liver disease
- Treating unhealthy alcohol use in older adults
- Treating unhealthy alcohol use in women
- Managing alcohol use in pregnancy
- Treating co-occurring alcohol use disorders and depression
- Long-term management of co-occurring alcohol use disorder and major depression
- Tools & Resources
- References