please find the powerpooint presentation on Alcoholic liver disease presented by sunil kumar daha (me) and my friend Bishnu Ranjan Patel.

1. Alcoholic Liver Disease
Presented by:
Bishanu Ranjan Patel
Sunil Kumar Daha

2. Introduction
• Hepatic manifestations of alcoholic over consumption.
1. Fatty liver
2. Alcoholic Hepatitis
3. Alcoholic cirrhosis
• ALD doesn’t occur below a threshold of alcohol consumption
of :-
• <14units/week in women
• <21units/week in men
• Alcoholics vs ALD
1 unit-8 gm

3. Risk factors
• Quantity of alcohol
— In men, 40–80 g/d of ethanol produces fatty liver;
in women, 20-40 g/d is enough
— 160 g/d for 10–20 years causes hepatitis or cirrhosis
• Drinking pattern: Continuous vs. intermittent
• Gender: Female twice > men
• Genetics: Monozygotic twins Vs. dizygotic
• Nutrition
• Obesity
• Malnutrition specially choline-deficient diet
• Hepatitis C infection

5. Amount of alcohol in average drink
Alcohol type % alcohol
by volume
Amount Units
Beer 3.5
9
440 ml
440 ml
2
4
Wine 10
12
125 ml
750 ml
1
9
Alcopops 6 330 ml 2
Sherry 17.5 750 ml 13
Vodka/rum/gin 37.5 25 ml 1
Whisky/brandy 40 700 ml 28
Ref: Devidson’s 22nd edition

6. Metabolism of Alcohol
Ethanol(80%)
Acetaldehyde
Acetyl co-A and Acetate
Ethanol(20%)
Acetate
•Alcohol is metabolized in liver via 2 pathways :-
NAD
NADH
Cyt CYP2E1Alcohol
dehydrogenase
Aldehyde
dehydrogenase

7. Pathogenesis

8. Malondialdehyde
acetaldehyde

9. Pathological changes

10. 1. Alcoholic fatty liver
• Accumulation of triglycerides within hepatocytes
• Can be reversed if alcohol consumption is stopped or
reduced significantly
• Has a good prognosis, disappears after 3 months of
abstinence

11. 2. Alcoholic Hepatitis
• Hepatocyte injury is characterized by-
• Mallorys Hyaline, Centrilobular necrosis, Fatty change,
Hepatocyte ballooning, PMN infiltrate, Pericellular fibrosis
• Worse prognosis than fatty liver disease
• Precursors to cirrhosis
• Potentially reversible with alcohol abstinence

12. 3. Alcoholic Liver cirrhosis
• “A condition in which there is continuing fibrosis
resulting in the subdivision of the liver into nodules of
proliferating hepatocytes surrounded by scar tissue as
the direct result of chronic alcohol abuse.”
• Irreversible condition even with abstinence
• Present in up to 50% of patients with biopsy-proven
alcoholic hepatitis

13. Contd…
Vicious circle of
 Chronic inflammation
 Fibrosis
 Nodular regeneration
 Distortion of architecture
 Hepatocellular necrosis

14. Clinical syndromes of Alcoholic Liver
Diseases
Fatty Liver Alcoholic
hepatitis
Cirrhosis
• Asymptomatic
• Abnormal liver
biochemistry
• Normal or large
liver
• RUQ discomfort
• Nausea
• Rarely jaundice
• Asymptomatic
• Jaundice
• Malnutrition
• Hepatomegaly
• Features of portal
hypertension e.g.
ascites
• encephalopathy
• Stigmata of chronic
liver diseases
• Ascites/varices/enc
ephalopathy
• Large, normal or
small liver
• Hepatocellular
carcinoma

15. Investigations
• Macrocytosis in the absence of anaemia, may suggest
and support a history of alcohol misuse
• Unexplained rib fractures, particularly bilateral, on a
chest X-ray are also suggestive of alcohol misuse
• Presence of jaundice suggests alcoholic hepatitis
Test Comment
AST Increased two- to seven fold, <400 U/L, greater than ALT
ALT Increased two- to sevenfold, <400 U/L
AST/ALT Usually >1
GGTP Not specific to alcohol, easily inducible, elevated in all forms
of fatty liver
Bilirubin May be markedly increased in alcoholic hepatitis despite
modest elevation in alkaline phosphatase
PT Prolonged
Albumin Hypoalbuminemia
PMN If>5500/ml Predicts severe alcoholic hepatitis when
discriminant function > 32

16. Contd…
• We can also send for:
• Ultrasonography:
 fatty infiltration and determine liver size
portal vein flow reversal, ascites, and intra-abdominal
collaterals indicates serious liver injury with less potential
for complete reversal of liver disease
• Liver Biopsy:

17. Prognosis
• Critically ill patients with alcoholic hepatitis have short-
term (30-day) mortality rates >50%
• Presence of ascites, variceal hemorrhage, deep
encephalopathy, or hepatorenal syndrome predicts a
dismal prognosis
• Pathologic stage of the injury by liver biopsy

18. Discriminant Function (DF)
• Aka ‘Maddrey score’
DF = (4.6 x increase in PT sec. )) + (serum bilirubin mg/dl)
• To assess prognosis in alcoholic hepatitis
A value over 32 implies severe liver disease with a poor
prognosis

19. Glasgow Alcoholic Hepatitis Score
Score 1 2 3
Age < 50 > 50
WCC (× 109/L) < 15 > 15 > 2.0
Urea (mmol/L) < 5 > 5 > 250
PT ratio < 1.5 1.5-2.0
Bilirubin
(μmol/L)
< 125 125-250
A score > 9 is associated with a 40% 28-day survival,
compared to 80% for patients with a score < 9

20. Model for End-stage Liver Disease
(MELD)
1-year survival (%)
MELD score No complications Complications
< 9 97 90
10-19 90 85
20-29 70 65
30-39 70 50
MELD from SI units
10 × (0.378[In serum bilirubin (μmol/L) + 1.12[In INR] + 0.957[In serum
creatinine (μmol/L)] + 0.643)
MELD from non-SI units
3.8 [In serum bilirubin (mg/dL)] + 11.2 [In INR] + 9.3 [In serum creatinine
(mg/dL)] + 6.4

21. Management
1. Alcohol Abstinence
2. Nutritional Support
3. Corticosteroid Therapy
4. Pentoxifylline
5. Liver Transplantation
* We also have to manage for :-
• Alcohol withdrawal and Wernicke's encephalopathy
• Treatment for complications of cirrhosis, such as
variceal bleeding, encephalopathy and ascites

23. 1. Alcohol abstinence
• Most important treatment of all
• Effective in preventing progression of disease
• Alcohol withdrawal syndrome and Wernicke’s encephalopathy need
parallel treatment too

24. 2. Nutritional support
• Protein supplementation
• Vit A
• Folate
• Vit B6
• Thiamine

25. 3. Corticosteroids
• Glucocorticoids have been found to be beneficial in
patients with severe alcoholic hepatitis (Maddrey’s DF
score ≥32).
• Survival rate found to be increased in those with
Glasgow score >9
• Sepsis is the main side effect
• Should not be given to patients with active GI bleeding,
sepsis, renal failure or pancreatitis.

26. 4. Pentoxifylline
• Anti- TNF action
• Reduce incidence of hepato-renal failure
• Given in severe alcoholic hepatitis in whom
corticosteroids cannot be given

27. References
• Harrison’s Principle of Medicine,19th edition
• Davidson’s Principle and Practice of Medicine, 22nd
edition
• Kumar and Clark’s Clinical Medicine, 8th edition

28. Thank You!