Occasional Survey

ALCOHOLIC LIVER DISEASE: MORPHOLOGICAL MANIFESTATIONS

Severe alcoholic hepatitis (SAH) is a grave condition, and the presence of acute kidney injury (AKI) further jeopardizes patient survival. However, the impact of AKI on survival in SAH has not been assessed from this region of Asia.

This study was conducted on consecutive alcohol-associated liver disease (ALD) patients hospitalized in Gastroenterology Department, SCB Medical College, Cuttack, India, between October 2016 and December 2018. On diagnosis of SAH (mDF score ≥32), demographic, clinical, and laboratory parameters were recorded, and survival was compared between patients with and without AKI (AKIN criteria). In addition, survival was compared among SAH patients defined by other criteria and prognostic models in the presence and absence of AKI.

309 (70.71%) of ALD patients had SAH, and 201 (65%) of them had AKI. SAH patients with AKI had higher total leucocyte count, total bilirubin, serum creatinine, serum urea, INR, MELD (UNOS), MELD (Na+), CTP score, mDF score, Glasgow score, ABIC score, and increased prevalence of acute on chronic liver failure (ACLF) as per EASL-CLIF Consortium criteria (P < 0.001). Further, they had prolonged hospital stay, and increased death during hospitalization, at 28 days as well as 90 days (P < 0.001). Significant differences in survival were also seen in SAH (as per MELD, ABIC, and GAHS criteria) patients above the marked cut offs in respect to AKI.

Over two-thirds of ALD patients had SAH, and about two-thirds had AKI. Patients with SAH and AKI had an increased prevalence of ACLF, longer hospital stay, and increased mortality during hospitalization at 28 days and 90 days.

SAH is a critical condition, and the presence of AKI negatively affects their survival. Hence, early identification of SAH and AKI, as well as early initiation of treatment, is crucial for better survival. Our study from the coastal part of eastern India is the first to demonstrate the prevalence of SAH among patients with ALD along with the prevalence of AKI among SAH patients in this region. This knowledge will be helpful in managing these patients from this region of world.

Fatty liver disease (FLD) has a wide histopathology spectrum including simple steatosis, steatohepatitis with or without fibrosis, and cirrhosis that may be complicated by hepatocellular carcinoma (HCC). The two main entities that comprise FLD, alcohol-related liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) associated to metabolic dysfunction, have both similarities and differences. In this chapter, some of the features that are common to both are considered, followed by a review of the pathogenetic and pathological features of each and discussion on how the two can be distinguished clinically and histopathologically. NAFLD concurrent with other liver disease, NAFLD in other clinical settings and treatment options are also discussed.

El consumo excesivo de alcohol representa un problema de salud a nivel global. Un porcentaje relevante de la morbimortalidad asociada se debe a la hepatopatía alcohólica, que comprende un espectro clínico muy diverso. En sus fases más tempranas, la ausencia de síntomas específicos confiere mayor importancia a las estrategias de cribado. La detección de un consumo excesivo de alcohol debe ir seguida tanto de la realización de intervenciones dirigidas a la disminución del consumo, como de pruebas que permitan descartar o diagnosticar la enfermedad hepática. En este sentido, han cobrado relevancia en los últimos años los métodos no invasivos de detección de fibrosis como la elastografía. El tratamiento de la hepatopatía alcohólica se basa en el cese del consumo de alcohol, lo que determinará el pronóstico no solo en los estadios iniciales sino también en la cirrosis descompensada. Una forma particular de presentación es la hepatitis alcohólica, con sus alteraciones bioquímicas e histológicas características. En la hepatitis alcohólica grave, que conlleva una alta mortalidad, el único tratamiento recomendado actualmente son los corticoides. Dado que solo se ha demostrado beneficio a corto plazo y que un porcentaje importante de los pacientes no responden al tratamiento, continúan en estudio nuevas terapias.

Excessive alcohol intake is a worldwide problem. A high percentage of worldwide morbidity-mortality rates are associated to alcoholic liver disease, which comprehend a very wide clinical spectrum. Screening strategies are more important in earliest stages, when symptomatology is non-specific. Once abusive alcohol intake is detected, interventions aimed at decreasing alcohol intake as well as diagnostic tests have to be performed. So, in recent years non-invasive methods for the diagnosis of liver fibrosis, like elastography, have gained relevance. Alcohol abstinence is the treatment of alcoholic liver disease, conditioning prognosis both in early cirrhosis and in decompensated cirrhosis. A special type of alcoholic liver disease is the alcoholic hepatitis and its typical biochemical and histological features. Currently, corticoids are the only possible treatment for severe alcoholic hepatitis (mortality rates are high). Because corticoid therapy only has beneficial effect at short term and shows a low response rate, nowadays new therapies are being researched.

To date, studies into the natural history of alcohol-related liver disease (ALD) have lacked long-term follow-up, large numbers of participants, or both. We performed a systematic review to summarise studies that describe the natural history of histologically proven ALD.

PubMed and Medline were searched for relevant studies according to pre-specified criteria. Data were extracted to describe the prevalence of ALD, histological progression of disease and mortality. Single-proportion meta-analysis was used to combine data from studies regarding rates of progression or mortality.

Thirty-seven studies were included, reporting data from 7,528 participants. Amongst cohorts of hazardous drinkers, on average 15% had normal histological appearance, 27% had hepatic steatosis, 24% had steatohepatitis and 26% had cirrhosis. The annualised rates of progression of pre-cirrhotic disease to cirrhosis were 1% (0–8%) for patients with normal histology, 3% (2–4%) for hepatic steatosis, 10% (6–17%) for steatohepatitis and 8% (3–19%) for fibrosis. Annualised mortality was 6% (4–7%) in patients with steatosis and 8% (5–13%) in cirrhosis. In patients with steatohepatitis on biopsy a marked difference was seen between inpatient cohorts (annual mortality 15%, 8–26%) and mixed cohorts of inpatients and outpatients (annual mortality 5%, 2–10%). Only in steatosis did non-liver-related mortality exceed liver-specific causes of mortality (5% per year vs. 1% per year).

These data confirm the observation that alcohol-related hepatic steatohepatitis requiring admission to hospital is the most dangerous subtype of ALD. Alcohol-related steatosis is not a benign condition as it is associated with significant risk of mortality.

Knowledge of the natural history of a disease allows clinicians and patients to understand the risks that are associated with a medical condition. In this study we systematically gathered all the published data regarding the natural history of alcohol-related liver disease in people who had a liver biopsy. We used this data to define the prevalence of the disease, the annual risk of progression to cirrhosis and the annual risk of death at each stage of the disease.

The harmful use of alcohol has been estimated to cause approximately 3.3 million deaths every year, corresponding to nearly 6% of all deaths globally. Therefore, the effective management and treatment of alcoholic liver disease is a pertinent public health issue. In the following Clinical Practice Guidelines, the latest data on the treatment and management of alcohol-related liver disease will be reviewed and up to date recommendations for clinical management will be provided.