Alcohol-Related Liver Disease Initial Assessment

Clinical Presentation

The signs, symptoms, and severity of liver disease can be variable between individuals and histological stages.  

Signs and Symptoms of Liver Disease  

Patients with liver disease may present with various signs and symptoms related to portal hypertension such as the presence of abdominal wall collaterals, ascites, hepatic encephalopathy, splenomegaly, and a venous hum. Signs of alcohol abuse and hepatic injury includes malnutrition and muscle wasting, jaundice, cutaneous telangiectasia, palmar erythema, finger clubbing, Dupuytren’s contracture, rhinophyma, spider angioma, peripheral neuropathy, parotid gland enlargement, and signs of gynecomastia and hypogonadism may also be present. Other things that should be noted are asymptomatic patients, hepatomegaly (which is the most common sign in patients with alcohol-related liver disease [ALD]), hepatic bruit, alcohol withdrawal (eg tremors, tachycardia, agitation, delirium tremens), anorexia and weight loss, and systemic inflammatory response syndrome (SIRS) (defined as the presence of ≥2 of the following: Heart rate of >100 beats per minute, respiratory rate of >12 breaths per minute, temperature of >38⁰C or <36⁰C, WBC count of >12,000 or <4,000 mm).    

Well-compensated Cirrhosis  

Patients with well-compensated cirrhosis may be asymptomatic and have a normal physical exam. Steatosis and steatohepatitis are often coexistent, and patients may have hepatomegaly and/or splenomegaly. In such patients, signs of portal hypertension may dominate. In more advanced cases of cirrhosis, the liver decreases in size and the left hepatic lobe becomes more prominent; the entire liver has a hard and nodular consistency. Lastly, it must be noted that splenomegaly of various degrees is frequent.  

Decompensated Cirrhosis  

Patients with decompensated cirrhosis may present with jaundice, variceal bleeding, infections, muscle wasting and cachexia, ascites and venous collateral circulation, spider angiomata, palmar erythema, Dupuytren’s contracture, parotid and lacrimal gland enlargement. If there is hypoalbuminemia, the patient may have Muehrcke’s nails or white nails. Clubbing of fingers may be present in patients with arteriovenous pulmonary shunting. Hepatic encephalopathy or hepatorenal syndrome may also be present.

Diagnosis or Diagnostic Criteria

Alcohol use disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a problematic pattern of alcohol use which leads to clinically significant distress or impairment. AUD replaces the former categories of alcohol abuse and dependence. There are 11 diagnostic criteria and the presence of at least 2 of these in the last year indicates AUD. The severity of AUD ranges from mild (2 to 3 criteria met) to moderate (4 to 5 criteria met), and severe (≥6 criteria met).

Alcoholic Hepatitis  

The clinical diagnosis of alcoholic hepatitis includes jaundice in the last 8 weeks, daily alcohol use of >60 g (males) or >40 g (females) for ≥6 months with abstinence of <60 days prior to developing jaundice, aspartate aminotransferase (AST) >50, AST/alanine aminotransferase (ALT) ratio of >1.5 with both levels <400 IU/L, and serum total bilirubin >3 mg/dL. Potential confounding factors are possible hepatic disease (metabolic or drug-induced liver disease or ischemic hepatitis), ambiguous history of alcohol intake, or atypical lab tests.

Screening

Screen For Alcohol Use Disorder (AUD)   

The US National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a single initial screening question “How many times in the last year have you had ≥5 drinks in a day (for men) or ≥4 drinks in a day (for women)?” A positive answer warrants administration of the Alcohol Use Disorders Identification Test (AUDIT) tool.  

The AUDIT is a widely used, validated, 10-question screening tool developed by the World Health Organization (WHO) to recognize risky and harmful alcohol consumption. An AUDIT score of ≥8 indicates hazardous and harmful alcohol use while a score of ≥20 indicates alcohol dependence or moderate to severe AUD. AUDIT-C is a shorter version of AUDIT which uses the first 3 questions of AUDIT on alcohol consumption and is better in identifying alcohol misuse than the CAGE (Cut down, Annoyed, Guilty, Eye-opener) and other questionnaires. An AUDIT-C score of ≥4 requires further assessment using the full AUDIT. The US Preventive Services Task Force (USPSTF) does not recommend the outdated CAGE for screening as it does not identify patients who could benefit from a brief intervention. The Fast Alcohol Screening Test (FAST) is composed of questions 3, 5, 8, and 10 from the AUDIT and is used in emergency settings; a score of ≥3 indicates hazardous alcohol use.  

Various interventions are provided to the patient based on the AUDIT score: 0 to 7 is alcohol education, 8 to 15 is simple advice, 16 to 19 is simple advice with brief counseling and continued monitoring, and 20 to 40 requires a specialist referral for diagnostic evaluation and treatment. A patient with an AUDIT-C score of ≥4, a FAST score of ≥3 or is a binge drinker (≥5 drinks in men or ≥4 drinks in women consumed in 2 hours) should be offered brief intervention and referral to treatment.  

Other screening tools include the Alcohol, Smoking, and Substance Involvement Screening Tool (ASSIST), the Michigan Alcoholism Screening Test (MAST), and the Lifetime Drinking History.  

It is suggested to standardize the measure of alcohol in a drink to 10 g of pure alcohol as used by the European standard and WHO. The toxic daily threshold of alcohol consumption is 40 to 80 g for males and 20 to 40 g for females for 10 to 12 years (≥5 drinks per day in males and ≥4 drinks per day in females). Heavy alcohol use for >5 years, ie >3 drinks per day for males and >2 drinks per day for females, increases the risk for ALD. Patients with AUD should also be screened for coexisting psychiatric disorders and other addictions, eg nicotine.

Alcohol-Related Liver Disease_Initial Assesment