Alcoholic and Toxic Liver Disease: Diagnosis and Treatment

Diagnosis

• The diagnosis of drug– and toxin–induced liver injury is often difficult. A detailed history and physical examination are essential, and the physician should investigate the possibility of accidental, environmental, and intentional exposures.
  
  In suspected cases of alcoholism, a careful history and the “CAGE criteria” may be used to establish the diagnosis of alcoholism. A positive response to at least two questions is seen in the majority of people with alcoholism.
• Have you felt the need to Cut down drinking?
• Have you ever felt Annoyed by criticism of drinking?
• Have you had Guilty feelings about drinking?
• Do you ever take a morning Eye opener?

• Blood testing is often the most important aspect of diagnosis. Blood tests are used to evaluate liver function and nutritional status, assess coexisting disease, and screen for toxins and drugs.
• In some cases, a biopsy may be necessary to identify liver damage and evaluate for various liver diseases, including cancer and cirrhosis.
• Ultrasound, abdominal x–ray, CT scan, or MRI may be indicated to further evaluate the liver and rule out other abdominal disorders.

Treatment

• Suspected drugs or toxins should be immediately stopped. Recovery often occurs after withdrawal of the offending substance.
• Abstinence from alcohol is essential, even when alcohol was not the cause of damage. It can aggravate the damage caused by other substances. Individuals with alcohol problems should seek counseling on alcohol cessation, including referral to Alcoholics Anonymous, psychotherapy, or similar programs.
• Weight reduction is a requirement for overweight persons.
• Acetaminophen overdose is a medical emergency treated with activated charcoal and n–acetylcysteine.
• Other than treatment for acute acetaminophen toxicity, specific therapies are generally not available. In cases of allergic reactions to medications (e.g., penicillin) or alcoholic hepatitis, corticosteroids may be useful.
• Supportive treatments in cases of liver failure include nutritional changes (see Nutritional Considerations), vitamin K supplementation to improve coagulation, and correction of micronutrient deficiencies (e.g., folate supplementation).
• Liver transplantation may be required in patients with severe acute liver failure or chronic liver disease.