00:00
Let's begin our next case.
00:03
A 67-year-old woman is
seen in clinic for a routine visit.
00:07
She feels well, her only past
medical history is hypertension.
00:11
She drinks 6 cans of beer per night.
00:15
She recently traveled to Mexico
but has not had any diarrhea.
00:19
Her vitals are normal.
00:20
She has mild hepatomegaly on physical exam.
00:24
Lab studies are shown here:
So her ALT is 85 (U/L), AST is 180
(U/L) and her bilirubin is 0.8 (mg/dL).
00:32
What is the most likely diagnosis?
So let's point out that she
has an alcohol use disorder.
00:40
She has recent travel to Mexico which does
raise some suspicion for hepatitis A or E
but notably, she has no symptoms
of either of these diseases.
00:51
And she has this AST to ALT
ratio of greater than 2 to 1.
00:57
We'll discuss what
that means in a bit.
01:01
So, let's talk now about
alcohol-induced liver disease.
01:05
In general, this is just inflammation
of the liver caused by alcohol.
01:10
Patients often have a serum AST and ALT elevation
of 2 to 6 times the upper limit of normal.
01:19
The typical ratio is an AST to
ALT ratio of 2 to 1 or greater.
01:26
Patients may be either
asymptomatic with just fatty liver
or they may be symptomatic and
develop alcoholic hepatitis.
01:34
So here on the right you can see the
natural progression of this disease.
01:38
You begin with a normal liver.
01:40
With recurrent alcohol use,
you develop fatty liver or steatosis
With ongoing use, you can develop
inflammation, so steatohepatitis.
01:49
This can then progress to fibrosis, cirrhosis and
lastly, the dreaded hepatocellular carcinoma.
01:58
So, patients with this disease may present
with jaundice, a loss of appetite or anorexia
and they may also have
tender hepatomegaly.
02:08
The treatment depends on the
severity of their disease.
02:12
So if it is mild, you just do supportive care and
counsel them to remain abstinent from alcohol.
02:19
If their disease is moderate to severe with
inflammation, you could consider prednisone.
02:27
So, let's return to our case.
02:30
We have a 67-year-old woman
with an alcohol use disorder,
a recent travel to Mexico but no
symptoms of hepatitis A or E
and she has an AST to ALT
ratio of greater than 2 to 1
and both of these tests are somewhat abnormal
within the 2 to 6 times the upper limit of normal.
02:49
So this ratio with our clinical picture should
prompt you to think of alcoholic liver disease.
02:55
She is asymptomatic so she likely
just has alcoholic steatohepatitis
and she should be counseled
for her alcohol use disorder.