(Page 2 of 7)

In later stage cirrhosis with complications (decompensated disease), patients may have muscle wasting, ascites, and the adaptation of smaller vessels to handle increased blood flow (venous collateral circulation). Other common signs are small star-shaped vessels (spider angiomata) on the skin of the upper torso, blotchy redness on the palms (palmar erythema), and contracture of the palm tissue, causing the ring and pinky finger to bend into the palm (Dupuytren's palmar contracture). Enlargement of the parotid gland (one of the salivary glands) and the lacrimal glands often is seen. Enlargement of the fingertips may be found in patients who develop a problem with the way blood passes through the lungs, resulting in blood not being properly oxygenated. Other physical signs, which may be found during examination with a flexible fiberoptic instrument (endoscopy), include changes in the stomach lining that occur with portal hypertension, as well as engorged veins in the esophagus, stomach, or another part of the gastrointestinal tract, which expand as a consequence of increased pressure in the blood flow of the venous system. Patients with hepatic encephalopathy may have slow reaction times and muscle tremors causing involuntary jerking of the hands.

ALD cannot be diagnosed based on any of the physical signs and symptoms alone. Laboratory tests often assist in the diagnosis of ALD. Almost all patients will have elevated liver enzymes. The level of the enzyme aspartate aminotransferase (AST) will exceed that of alanine aminotransferase (ALT), but both will be below 300 international units per milliliter (IU/ml). When the ratio of AST to ALT is greater than 2, the most likely diagnosis is ALD. In some studies, more than 80 percent of patients attain this ratio.

Elevated blood levels of the liver enzyme gamma glutamyltransferase (GGT) indicate heavy alcohol use and liver injury. This test has greater ability to correctly test positive (sensitivity) but less ability to correctly test negative (specificity) than AST or ALT tests. Of the three enzymes, GGT is the best indicator of excessive alcohol consumption, but because GGT is present in many organs and because some drugs raise GGT levels, high GGT levels are not necessarily an indicator of alcohol abuse.

Chronic alcohol consumption also may be associated with abnormally high triglyceride levels (hypertriglyceridemia), high blood levels of uric acid (hyperuricemia), and low amounts of potassium (hypokalemia) and magnesium, as well as an elevated index of red blood cell size (mean corpuscular erythrocyte volume). Hyperuricemia and hypertriglyceridemia often normalize with abstinence, and hypokalemia normalizes with adequate potassium replacement. Elevated MCV often is found in people who ingest more than 50 grams of alcohol per day,1 with sensitivity of 27 to 52 percent and specificity of 85 to 90 percent. (1 In the United States, a drink is considered to be 0.5 ounces [oz] or 15 grams of alcohol, which is equivalent to 12 oz of beer, 5 oz of wine, or 1.5 oz of 80-proof distilled spirits.) The blood protein known as carbohydrate-deficient transferrin frequently is used to detect current or recent alcohol abuse, especially consumption in excess of 60 grams per day, but there are no ideal tests to identify continuing alcohol intake.

An increased number of white blood cells (leukocytosis) and decreased number of platelets (thrombocytopenia) are common in alcoholic hepatitis. Thrombocytopenia may be transitory, but in patients with concomitant cirrhosis, it is persistent. Markers of severe alcoholic hepatitis or cirrhosis include elevated levels of bilirubin (a yellow-orange substance generated in the liver), prolonged time required for a blood sample to clot (prothrombin time), and a low level of the main circulating protein in the bloodstream (albumin), which is synthesized by the liver (hypoalbuminemia).

If this value exceeds 32, the mortality rate during a current hospitalization may exceed 50 percent. There also is evidence that blood concentrations of proteins (cytokines) that promote inflammation - such as tumor necrosis factor alpha (TNF-α), interleukin-6, and interleukin-8 - correlate with mortality in patients with alcoholic hepatitis, but levels of these cytokines are not determined in routine clinical practice.

Liver biopsy mainly is used to clarify atypical cases, to better define the contribution of alcohol in patients with possible non-alcohol-related coexisting conditions (hepatitis C, use of lipid-lowering medications), and to determine the severity of liver disease. Many laboratories are conducting research to evaluate biomarkers or identifier proteins for detecting ongoing alcohol abuse and ALD. The importance of genetic variations in alcoholism and ALD among individuals also is under active investigation. New tests may provide novel ways of identifying alcohol abuse, susceptibility to liver injury, and mechanisms of liver injury, and of detecting and monitoring liver injury.

Tags: Alcoholism

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.