Alcoholic hepatitis vs cirrhosis, Specifics, Symptoms, Clinical Signs, Management & Treatment for Alcoholism

Alcoholic Hepatitis is one of many diseases caused by heavy alcohol consumption. It develops when a person drinks large amounts of alcohol over an extended period of time. This leads to an inflammatory condition of the liver. Alcoholic Hepatitis is an acute, toxic degenerative, and inflammatory lesion of the liver seen in alcoholics after excess ethanol consumption. Characterized by necrosis, inflammation, and, in some instances, alcoholic hyaline. It does not necessarily include fatty liver, fibrosis, or cirrhosis of the alcoholic, but may frequently be associated with these conditions.

This is a very dangerous and life-threatening condition, there’s a high percentage of people who die from this disease between the first and sixth months. This is why appropriate diagnosis and treatment are essential. As stated by the scientific article ‘Alcoholic Hepatitis: Current Challenges and Future Directions’, Ashwani K.Singal, Clinical Gastroenterology and Hepatology, Volume 12, Issue 4, “Alcoholic Hepatitis is a distinct clinical syndrome among people with chronic and active alcohol abuse, with a potential for 30%–40% mortality at 1 month among those with severe disease. Corticosteroids or pentoxifylline are the current pharmacologic treatment options, but they provide only about 50% survival benefit”.

The liver fulfills an extremely important function for the human body. It filters the blood of toxins, breaks down proteins, and creates bile to help the body absorb fats. Alcoholic Cirrhosis is a disease caused by excessive alcohol consumption. When a person drinks alcohol heavily over the course of decades, the body starts to replace the liver’s healthy tissue with scar tissue. As the disease progresses, and more of the healthy liver tissue is replaced with scar tissue, the liver will stop functioning properly. After heart disease and cancer, alcoholic cirrhosis is the third most common cause of death in people aged 45-65 years.

According to the scientific piece, ‘Alcohol use disorder and the liver’ published by John Wiley & Sons Ltd., “alcohol use disorders (AUD) cause a range of physical harms, but the major cause of alcohol-related mortality is an alcohol-related liver disease (ALD), in some countries accounting for almost 90% of alcohol-related deaths. The risk of ALD has a positively correlated relationship with increasing alcohol consumption but is also associated with genetic factors, other lifestyle factors, and social deprivation. ALD includes a spectrum of progressive pathology, from liver stenosis to fibrosis and liver cirrhosis. There are no specific treatments for liver cirrhosis, but abstinence from alcohol is key to limit the progression of the disease”.

Excessive drinking can cause scarring of the liver, a condition known as cirrhosis. Although most individuals who drink excessively do not develop cirrhosis, how much alcohol causes cirrhosis is usually unclear. Drinking too much over time can lead to alcoholic hepatitis and then to alcoholic cirrhosis.

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), how much alcohol causes cirrhosis is dependent on how quickly a person drinks, how much they weigh, and how often they drink. Individuals who consume more than 6 servings of alcohol per day over several years are likely to develop cirrhosis; however, how much alcohol causes cirrhosis in any given individual can vary.

The association between alcohol abuse and liver damage is known since the times of ancient Greeks. The clinical spectrum of alcoholic liver injury varies from asymptomatic hepatomegaly to profound hepatocellular failure with portal hypertension. The clinical picture tends to be more florid in individuals with more advanced liver injury. The alcoholic liver injury appears to progress from fatty changes through alcoholic hepatitis to cirrhosis. 

The majority of the individuals who abuse alcohol will develop fatty changes in their liver at some stage of their drinking career. However, only 20% of such individuals will develop cirrhosis. The apparent predisposition of certain people to develop alcoholic cirrhosis is unknown. Fatty liver, though indicating a profound metabolic disturbance within the liver, is not necessarily harmful. Certainly, cirrhosis may develop in an alcoholic who has never had fatty change and isolated fatty change has not been shown to proceed directly to cirrhosis. Alcoholic hepatitis develops in only a proportion of drinkers even after decades of abuse and is assumed to be a pre-cirrhotic lesion, although its natural history is not well understood.

Thus in approximately 50% of individuals, alcoholic hepatitis may persist for several years and in 10% of individuals, the lesion may heal despite continued alcohol abuse. It has therefore been suggested that although alcoholic hepatitis may contribute, when present, to the evolution towards cirrhosis, it is not a sine qua non of such progression. Though most alcoholics may have a combination of alcoholic hepatitis and cirrhosis on biopsy and more or less similar clinical and biochemical features, certain features may help in differentiating the two conditions.

Since alcoholic hepatitis is reversible and hepatic function improves over a period of time with abstinence, management consists predominantly of abstinence from alcohol and supportive care; whereas alcoholic cirrhosis once established is irreversible and hepatic function may not improve over time, management consists of abstinence from alcohol, treatment of complications and liver transplantation may be a viable option in carefully selected patients. Liver transplantation should not be done in patients with pure alcoholic hepatitis. Hence it is very essential to differentiate a patient having alcoholic hepatitis from the one having alcoholic cirrhosis as the management and prognosis are different.

Alcoholic hepatitis

• Patients with alcoholic hepatitis have been abusing alcohol till the time of presentation; they look more ill and being symptomatic present to a physician.
• Jaundice is usually one of the most common symptom. Some common mode of presentations are: jaundice – 50% of the patients, ascites in 30 – 60% and splenomegaly – 15% of the patients.
• Fever (even high grade) is seen in upto 50% of the subjects.
• Symptoms of variceal bleeding and hepatic encephalopathy are uncommon.

Alcoholic Cirrhosis

• Patients with alcoholic cirrhosis may not have abused alcohol for many years prior to presentation; most of them are well compensated, with only one-third being symptomatic.
• Ascites is usually the common symptom. Some common mode of presentations are: 40%, dilated abdominal wall veins – 60% and splenomegaly – 25% of the patients.
•  High grade fever is not seen (unless there is superadded infection).
•  Variceal bleeding and hepatic encephalopathy are quite common.

Alcoholic hepatitis

•  Spider naevi and palmar erythema may be florid.
• Features of portal hypertension – Ascites, dilated abdominal wall veins, splenomegaly and oesophageal varices are not a prominent features of pure alcoholic hepatitis.
• Liver is very large and tender on palpation; its surface is smooth and consistency is soft to firm.
• Arterial bruit may be heard over the liver area.

Alcoholic Cirrhosis

• Spider naevi and palmar erythema though seen, may not be florid.
• Features of portal hypertension are a prominent feature of alcoholic cirrhosis.
• Liver is mild to moderately enlarged or may not be palpable in advance cirrhosis and when palpable it is nontender, irregular with palpable nodules and firm in consistency.
• Unless there is superadded hepatocellular Unless there is superadded hepatocellular

Alcoholic hepatitis

• Alcoholic hepatitis is usually reversible on Alcoholic cirrhosis is generally considered to be not.
• Treatment consists of abstinence and proper nutritional support. Liver transplantation is not recommended at this stage.

Alcoholic Cirrhosis

• Alcoholic cirrhosis is generally considered to be an irreversible lesion once it is established.
• Apart from abstinence and treatment of complications, liver transplantation may be a viable option.

When it comes to Alcoholism treatment, it is normal to think of 12-step programs or 28-day inpatient rehab, but it becomes difficult to think of more options of treatment for this condition. There are a variety of treatment methods currently available. According to the National Institute on Alcohol Abuse and Alcoholism, there are three types of treatment: 

• Behavioral Treatments: are aimed at changing drinking behavior through counseling. They are led by health professionals and supported by studies showing they can be beneficial.
• Medications: Three medications are currently approved in the United States to help people stop or reduce their drinking and prevent relapse. They are prescribed by a primary care physician or other health professional and may be used alone or in combination with counseling.
• Mutual-Support Groups: Alcoholics Anonymous (AA) and other 12-step programs provide peer support for people quitting or cutting back on their drinking. Combined with treatment led by health professionals, mutual-support groups can offer a valuable added layer of support. Due to the anonymous nature of mutual-support groups, it is difficult for researchers to determine their success rates compared with those led by health professionals.