Alcohol-induced Liver Disease with Case

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.