Alcohol-Related Liver Disease Spectrum
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Direct answer
Alcohol-related liver disease is a spectrum running from simple steatosis through alcoholic hepatitis to fibrosis and cirrhosis, driven by acetaldehyde toxicity and oxidative stress. Steatosis is usually reversible with abstinence, whereas alcoholic hepatitis and cirrhosis carry significant mortality. Abstinence is the cornerstone of treatment at every stage, supported by nutrition and, in severe alcoholic hepatitis, corticosteroids.
What you must remember
- Steatosis: macrovesicular fatty change that often causes no symptoms and reverses within weeks of abstinence.
- AST to ALT ratio: a ratio above 2 suggests alcohol-related disease, with AST usually below 300 IU per litre.
- Gamma-GT and MCV: gamma-GT is raised in heavy drinking, and macrocytosis reflects alcohol toxicity and folate deficiency.
- Alcoholic hepatitis: jaundice, tender hepatomegaly, fever and a raised bilirubin, often in a patient with a short history of heavy drinking.
- Maddrey discriminant function: 4.6 times the prothrombin time prolongation over control plus bilirubin; a value of 32 or more defines severe alcoholic hepatitis.
- Severe alcoholic hepatitis: prednisolone 40 mg daily for 28 days after infection and renal failure have been excluded, with pentoxifylline now of doubtful benefit (STOPAH trial) and not recommended by most current guidelines.
- Thiamine: given before or with glucose to prevent Wernicke encephalopathy.
- Relapse prevention: baclofen or acamprosate supports abstinence, and both are used in patients with liver disease.
Where the exam tries to catch you
The stem gives a drinker with jaundice or a raised enzyme, and the trap is either to dismiss the diagnosis or to treat it without checking.
- Trap: dismissing liver disease because AST is only mildly raised Correct: alcohol-related disease typically shows AST below 300 IU per litre with a ratio above 2.
- Trap: giving steroids in alcoholic hepatitis with active infection Correct: infection is excluded first, because steroids are withheld when sepsis is present.
- Trap: giving glucose without thiamine Correct: thiamine should be given before or with glucose to prevent Wernicke encephalopathy.
- Trap: equating steatosis with irreversible damage Correct: steatosis reverses with abstinence, while fibrosis and cirrhosis mark the stage of significant damage.
Frequently asked questions
What AST to ALT ratio suggests alcohol-related liver disease?
An AST to ALT ratio above 2 suggests alcohol-related liver disease, particularly when the AST is below 300 IU per litre. The ratio is supportive rather than diagnostic, and it is read alongside gamma-GT and the history.
What is the Maddrey discriminant function threshold for severe alcoholic hepatitis?
A Maddrey discriminant function of 32 or more defines severe alcoholic hepatitis. It is calculated from the prothrombin time prolongation and the serum bilirubin, and it guides the decision to start corticosteroids.
Which drug is used in severe alcoholic hepatitis?
Prednisolone is used in severe alcoholic hepatitis, usually 40 mg daily for 28 days, once infection and renal failure have been excluded. Pentoxifylline was an older alternative but showed no survival benefit in the STOPAH trial, so it is now rarely advised.
Why is thiamine given to patients with alcohol-related liver disease?
Thiamine is given to prevent Wernicke encephalopathy, which can be precipitated by glucose in a thiamine-deficient patient. It is therefore given before or together with any glucose-containing fluid.