Alcoholic liver disease natural history, complications and prognosis

Alcoholic liver disease progresses through three stages (steatosis, alcoholic hepatitis, and cirrhosis) with the continued use of alcohol. Serious complications begin to occur with the development of alcoholic hepatitis, when portal hypertension, coagulopathies, and intractable jaundice. Complications of cirrhosis include hepatic encephalopathy and hepatocellular carcinoma. Prognosis varies dependent on level of progression of illness, and whether treatment is given. Prognosis can be measured using laboratory values, and three prognostic scores: The MELD score, the Glasgow Alcoholic Hepatitis Score, and the ABIC score.

Significant aspects regarding natural history of alcoholic liver disease include:^[1][2][3]

• Alcoholic liver disease is thought to progress through three main histological stages with the continued use of alcohol.
• Steatosis is the first stage occuring when triglycerides accumulate in hepatocytes.
• This is reversible with abstinence.
• Steatohepatitis or alcoholic hepatitis is the next stage characterized by:
  • Fatty change
  • Inflammation
  • Hepatocellular injury
  • Necrosis
• The last stage is cirrhosis which is characterized by:
  • Dense and diffuse micronodular fibrosis.
  • This stage is irreversible, and is a risk factor for the development of hepatocellular carcinoma.

Complications of alcoholic hepatitis include:^{[2][3][4][5][6][7]}

• Portal hypertension (ascites, variceal bleeding, hepatorenal syndrome)
• Coagulopathy
• Intractable jaundice

Complications of cirrhosis include:^{[2][3][4][5][6][7]}

• Hepatocellular carcinoma
• Hepatic encephalopathy

Poor prognostic factors of alcoholic liver disease include:^[4][5][8]

• Prolonged prothrombin time
• Serum Bilirubin >10 mg/dL
• Hepatic encephalopathy
• Azotemia
• Leukocytosis
• Unresponsive to steroid treatment
• Reverse portal flow on doppler ultrasound

Prognostic scores used to assess the prognosis of patients with alcoholic liver disease include:^[4][5][8]

• MELD score for cirrhosis
• Glasgow alcoholic hepatitis score (age, white blood cell, blood urea nitrogen, prothrombin time ratio, and bilirubin level)
• ABIC score – age, serum bilirubin, serum creatinine

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