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 should investigate the possibility of accidental, environmental, and intentional exposures.

Liver Function Tests

Elevations of aminotransferases such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are common and signify hepatocellular injury. A ratio of AST–to–ALT greater than 2 suggests alcoholic hepatitis.

Elevation of alkaline phosphatase out of proportion to the aminotransferases indicates cholestasis.

Low albumin concentration and extended prothrombin time (due to impaired synthesis of coagulation factors, primarily factor VII) reflect impaired hepatic synthetic function.

Bilirubin can be elevated due to either hepatocellular injury or cholestasis.

In suspected cases of alcoholism, a careful history and the CAGE criteria may be used to establish the diagnosis. A positive response to at least 2 questions is seen in the majority of patients with alcoholism and provides 93% sensitivity and 76% specificity.¹ Over 80% of nonalcoholics answer negatively to all 4 of the questions:

• 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?

Hematologic abnormalities may be present in patients with alcoholic liver disease, including macrocytosis, leukocytosis, thrombocytopenia, and folate deficiency.

Liver biopsy is usually diagnostic and can grade the severity of liver disease and exclude coexisting liver diseases. However, biopsy may not be necessary when the clinical presentation is classic.

Right–upper–quadrant ultrasound, abdominal x–ray, CT scan, MRI, and/or endoscopic retrograde cholangiopancreatography (ERCP) may be indicated to rule out other liver and abdominal pathology, such as cholecystitis, pancreatitis, cholecystitis, and malignancy.

Treatment

Suspected drugs or toxins should be discontinued immediately. Recovery often occurs after withdrawal of the offending substance.

Abstinence from alcohol is essential. Patients should be appropriately counseled on alcohol cessation, including referral to Alcoholics Anonymous, psychotherapy, or similar programs.

Weight reduction is a requirement for overweight patients.

Acetaminophen overdose is treated with activated charcoal and n–acetylcysteine.

Other than treatment for acute acetaminophen toxicity, specific therapies are generally not available. In cases of hypersensitivity reactions (eg, penicillin, procainamide) or alcoholic hepatitis, corticosteroids may be useful.

Supportive treatments in cases of liver failure include nutritional changes (see Nutritional Considerations below), vitamin K for coagulopathy, and correction of micronutrient deficiencies (eg, folate). Secondary complications (eg, hepatic encephalopathy) should be addressed as necessary.

Liver transplantation may be required in patients with severe acute liver failure or chronic liver disease.