Summary
Definition
History and exam
Key diagnostic factors
- abdominal pain
- hepatomegaly
- hematemesis and melena
- venous collaterals
- splenomegaly
- hepatic mass
- jaundice
- palmar erythema
- cutaneous telangiectasia
- asterixis
Other diagnostic factors
- ascites
- weight loss
- weight gain
- malnutrition and wasting
- anorexia
- fatigue
- confusion
- pruritus
- fever
- nausea and vomiting
- finger clubbing
- Dupuytren contracture
- leg swelling
- parotid gland enlargement
- gynecomastia
- hypogonadism
- dementia
- peripheral neuropathy
Risk factors
- prolonged and heavy alcohol consumption
- hepatitis C
- female sex
- cigarette smoking
- obesity
- age >65 years
- Hispanic ethnicity
- genetic predisposition
Diagnostic tests
1st tests to order
- serum aspartate aminotransferase (AST), alanine aminotransferase (ALT)
- serum AST/ALT ratio
- serum alkaline phosphatase
- serum bilirubin
- serum albumin, protein
- serum gamma glutamyl transferase (gamma-GT)
- CBC
- serum electrolytes, magnesium, phosphorus
- serum BUN and creatinine
- serum prothrombin time (PT), INR
- hepatic ultrasound
Tests to consider
- viral hepatitis serology
- serum iron, ferritin, transferrin
- urine copper (24-hour collection)
- serum ceruloplasmin
- serum antimitochondrial antibody (AMA)
- serum antinuclear antibody (ANA) and antismooth muscle antibody (ASMA)
- serum alpha-1 antitrypsin level
- serum ammonia
- serum folate
- noninvasive tests of liver elasticity
- CT abdomen, MRI abdomen
- liver biopsy
Emerging tests
- serum carbohydrate-deficient transferrin test
- serum mitochondrial AST
- Phosphatidylethanol (PEth)
Treatment algorithm
all patients
Contributors
Authors
Craig McClain, MD
Professor
Chief of Research Affairs
Associate Vice President for Health Affairs/Research
Division of Gastroenterology, Hepatology and Nutrition
Department of Medicine
University of Louisville School of Medicine
Louisville
KY
Disclosures
CM acts as a consultant for Nestlé, Durect, Allergan, Intercept, and DISCUS. He works for the Veterans Administration on a part time basis, has received grants from the NIH and VAMC, and is working on the update of the AGC nutritional guideline.
Luis Marsano, MD
Professor and Director of Hepatology
Division of Gastroenterology, Hepatology and Nutrition
Department of Medicine
University of Louisville School of Medicine
Louisville
KY
Disclosures
LM is on the speaker bureau for Salix (maker of Rifaximin - Xifaxan); Rifaximin is part of the therapy (supported by practice guidelines) of hepatic encephalopathy. He is also on the speaker bureau of Grifols (one of the makers of albumin for intravenous infusion); albumin is used as part of the treatment of spontaneous bacterial peritonitis (supported by practice guidelines).
Acknowledgements
Dr Craig McClain and Dr Luis Marsano would like to gratefully acknowledge Dr Mihir Patel, a previous contributor to this topic.
Disclosures
MP declares that he has no competing interests.
Peer reviewers
Lorenzo Leggio, MD, MSc
Postdoctoral Research Associate
Center for Alcohol and Addiction Studies
Brown University
Providence
RI
Disclosures
LL declares that he has no competing interests.
Nancy Reau, MD
Assistant Professor of Medicine
University of Chicago
Center for Liver Disease
Chicago
IL
Disclosures
NR declares that she has no competing interests.
Nick Sheron, MD, FRCP
Head of Clinical Hepatology and Senior Lecturer
Division of Infection, Inflammation and Immunity
University of Southampton Medical School
Southampton General Hospital NHS Trust
Southampton
UK
Disclosures
NS has received research grants from the Medical Research Council (MRC), Wellcome Trust, British Liver Trust, Alcohol Education Research Council, and various other funding bodies. He has undertaken paid consultancy work and received traveling expenses from pharmaceutical companies developing drugs for the treatment of inflammatory bowel disease and liver disease. He has been paid for medico-legal work in the areas of hepatitis C and alcohol-related liver disease. The following memberships and advisory work are unpaid apart from traveling expenses: EU Alcohol Forum, EU Alcohol Marketing Taskforce, Royal College of Physicians Alcohol Committee, Alcohol Health Alliance UK. NS has undertaken advisory and media work for the UK Department of Health, Home Office, Department of Transport, Cross Cabinet Strategy Committee, National Institute for Health and Care Excellence, Southampton City Council, UK Police, and British Liver Trust, and various other NGOs, local government, and other bodies. NS is an unpaid trustee of the Drinkaware Trust, an independent body set up by the UK Government to use industry resources to reduce alcohol-related harm. The Trust is funded entirely by the alcohol industry, with a board of trustees comprising 5 industry members, 5 members with alcohol-related health expertise, and 3 lay members.
Alastair MacGilchrist, MD, FRCP
Consultant Hepatologist
Royal Infirmary of Edinburgh
Edinburgh
UK
Disclosures
AM declares that he has no competing interests.
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