Most patients with alcohol-associated liver disease (ALD) are asymptomatic as the disease progresses, but non-specific complaints can appear:
- anorexia
- nausea and vomiting
- weakness
- jaundice
- weight loss
- abdominal pain
- fever
- diarrhea
In severe disease, portal hypertension and its complications can develop even before cirrhosis is established.
Physical examination
The main findings on physical examination are:
- hepatomegaly — in more than 75% of patients, regardless of disease severity
- hepatic tenderness
- spider angioma
- jaundice — in 60% of patients
- ascites — in 60% of patients
- splenomegaly
- edema
- palmar erythema
Laboratory findings
Serum aminotransferases. Even in patients with severe ALD the rise in serum aminotransferase levels is only modest, and the AST level is almost always below 400 U/L. Patients with ALD are deficient in vitamin B6, a cofactor for the activity of the ALT enzyme, so laboratory measurement of ALT underestimates it unless the sample is supplemented with vitamin B6. The AST:ALT ratio is greater than 2, a pattern that points to ALD.
Serum alkaline phosphatase can range from normal to values above 1000 U/L.
Serum bilirubin can range from normal to 20–40 mg/dL.
Serum albumin can range from normal to as low as 1–1.5 g/dL.
Other findings include anemia and prolongation of prothrombin time (PT), mostly in severely ill patients.
Histopathology
In most cases the clinical and laboratory findings are quite sensitive and specific for the diagnosis of ALD, but the definitive diagnosis always rests on histopathological study. The features on liver biopsy are:
- ballooning degeneration of hepatocytes
- Mallory bodies within damaged hepatocytes, surrounded by neutrophil infiltrates — Mallory bodies are the most specific histological alteration in ALD
- perivenular and centrilobular steatosis
- megamitochondria
In cirrhotic patients who have ALD, the cirrhosis nodules are mostly micronodular at diagnosis, but over time the micronodules convert to macronodules, which makes the cirrhosis indistinguishable from other causes of cirrhosis.
Hepatocellular carcinoma
Patients with ALD have a higher risk of progression to hepatocellular carcinoma (HCC), and the relative risk rises with the quantity of alcohol consumed daily. After abstinence, the relative risk of HCC falls by 6% each year, and after about 20 years it becomes similar to the control group.