Learning Outcome

1. Describe the presentation of alcoholic liver disease
2. Summarize the treatment of alcoholic liver disease
3. Recall the complications of alcoholic liver disease
4. List the nursing care management plans for alcoholic liver disease

Introduction

Alcoholic liver disease covers a spectrum of disorders beginning from the fatty liver, progressing at times to alcoholic hepatitis and culminating in alcoholic cirrhosis which is the most advanced and irreversible form of liver injury related to the consumption of alcohol.

There are three histologic stages of alcoholic liver disease:

1. Alcoholic fatty liver or steatosis - At this stage, fat accumulates in the liver parenchyma.
2. Alcoholic hepatitis[1] - Inflammation of liver cells takes place at this stage, and the outcome depends on the severity of the damage. Alcohol abstinence, nutritional support, treatment of infection, and prednisolone therapy in severe cases can help in the treatment of alcoholic hepatitis, but more severe cases lead to liver failure.
3. Alcoholic cirrhosis[2]-Liver damage at this stage is irreversible and leads to complications of cirrhosis and portal hypertension.

Alcohol is the most frequently misused drug throughout the entire world and in the United States of America.

In the United States, it is the leading cause of liver disease. It involves 61 percent of the American population, and among the 61 percent, 10 to 12 percent are heavy drinkers

Definition of one alcohol drink as per the Centers for Disease Control and Prevention (CDC) is a half-ounce or 13.7 g pure alcohol which is the amount of alcohol present in

• 12 oz beer (5% alcohol)
• 8 oz malt liquor (7% alcohol)
• 5 oz wine (12% alcohol)
• 1.5 oz 80-proof “hard-liquor” (40% alcohol)

The prevalence of alcoholic liver disease is highest in European countries. Daily consumption of 30 to 50 gram of alcohol for over five years can cause alcoholic liver disease. Steatosis can occur in 90% of patients who drink over 60g/day, and cirrhosis occurs in 30% of individuals with long-standing consumption of more than 40 g/day.

At-risk drinking definitions are below:

• Men: over 14 drinks per week or greater than four drinks per occasion
• Women and those over 65 years: over seven drinks per week or greater than three drinks per occasion

Definitions of significant drinking from a liver toxicity standpoint are as below (this history is essential to differentiate non-alcoholic fatty liver disease (NAFLD)  from alcoholic fatty liver disease (AFLD)

• Men: more than 21 drinks per week
• Women: over 14 drinks per week

Nursing Diagnosis

• Deficient knowledge
• Impaired body fluid balance
• Ineffective liver healing
• Risk of injury
• Imbalance in nutrition
• Risk for mental status deficits
• Ineffective coagulation and metabolism

Causes

Different factors, such as metabolic, genetic, environmental, and immunological, collectively play a role in alcoholic liver disease.

The liver tolerates mild alcohol consumption, but as the consumption of alcohol increases, it leads to the disorders of the metabolic functioning of the liver. The initial stage involves the accumulation of fat in the liver cells, commonly known as fatty liver or steatosis. If the consumption of alcohol does not stop at this stage, it sometimes leads to alcoholic hepatitis.  With continued alcohol consumption, alcoholic liver disease progresses to severe damage to liver cells known as  "alcoholic cirrhosis." Alcoholic cirrhosis is the stage described by progressive hepatic fibrosis and nodules.

Quantity and duration of alcohol intake are the highest risk factor for the development of liver disease. The beverage type plays a minimal role. Women are more susceptible than men. Obesity and high-fat diet also increases the risk of alcoholic liver disease. Concurrent hepatitis C infection is associated with younger age of onset, more advanced histological damage and decreased survival. Patatin-like phospholipase domain-containing protein 3(PNPLAP3) is associated with alcoholic liver cirrhosis. 

Assessment

Drinking history is the most important component, which includes the number of drinks per day and the duration of drinking. Given the lack of a unique diagnostic test, exclusion of other causes of liver injury is mandatory.

Personal and psychosocial factors are also important because excessive drinking is related to depression and other psychological diseases.

One should ask questions about diet, caloric intake, risk factors for malnutrition, and also about the risks for various types of chronic liver disease, including chronic viral hepatitis.

Questions about the following symptoms are necessary and informative:

• Nausea and vomiting
• Fever (in alcoholic hepatitis)
• Weakness
• Yellowish discoloration of eyes
• Loss of appetite
• Abdominal discomfort
• Increased thirst 
• Weight loss
• Fainting
• Confusion
• Alteration of the sleep-wake cycle
• Mood swings 

Physical Examination

The clinical definition of alcoholic hepatitis is a syndrome of liver failure where jaundice is a characteristic feature; fever and tender hepatomegaly are often present. The typical age at presentation is between 40 and 50 yrs, and it occurs in the setting of heavy alcohol use. Patients often report a history of intake of at least 30 to 50 g alcohol/day though over 100 g/day is common. Patients may be abstinent for weeks before admission. The cardinal sign is the rapid onset of jaundice. Other signs and symptoms include fever, ascites (SAAG greater than 1.1), and proximal muscle loss. Patients with severe alcoholic hepatitis may have encephalopathy. Typically, the liver is enlarged and tender.

General physical examination typically shows jaundice, hepatomegaly, splenomegaly, spider telangiectasias, Dupuytren contractures, testicular atrophy, decreased libido, parotid and lacrimal gland enlargement, white nails, Muecke's lines, asterixis and features of portal hypertension such as ascites, pedal edema, encephalopathy and caput-medusae (distended and engorged superficial abdominal veins).[3]

Abdominal tap (paracentesis) should take place if there is a suspicion of ascites.

Evaluation

Standard tests include:

• CBC (Complete blood count) to rule out the infection, look for complications of cirrhosis: anemia, thrombocytopenia, a leukemoid reaction in alcoholic hepatitis.
• LFTs (liver function tests): AST (aspartate aminotransferase) is markedly raised compared to ALT (alanine aminotransferase) in alcoholic liver disease, albumin is low, bilirubin is elevated. GGTP ( gamma-glutamyl transpeptidase) is usually elevated along with elevated triglyceride levels.
• Prothrombin time (PT) and INR (to assess liver synthetic function): Elevated value indicates more severe disease.
• Abdominal imaging (abdominal ultrasonography) to look for biliary obstruction and liver tumors.
• BMP (basic metabolic profile) should be ordered to look for renal failure and electrolyte disturbance (low levels of potassium, magnesium, and phosphorus).
• Ascitic fluid SAAG (serum-ascites albumin gradient) should be calculated to assess the reason for ascites if present.
• Screening blood tests for other causes of chronic liver disease, including viral hepatitis.
• Endoscopy to look for esophageal varices due to portal hypertension in patients with cirrhosis.
• A liver biopsy can make a definitive diagnosis in cases where the diagnosis is uncertain. It is used more often for evaluation of severity, staging, prognosis and treatment monitoring. At least 1.5-2 cm long sample of liver tissue is needed for accurate diagnosis of fibrosis. Liver biopsy has a risk of complication including life-threatening hemorrhage so it is reserved for cases where results of biopsy can make a difference in treatment plan. [3]

Medical Management

Treatment and management of alcohol liver disease depend on the stage of the disease. Medical Treatment 

• Alcohol abstinence, enrollment to detoxification programs
• Nutritional support
• Screening for hepatocellular carcinoma with 6 monthly ultrasonography and screening for esophageal varices in those with alcoholic cirrhosis
• Treatment of co-existent liver diseases such as Hepatitis B and C viral infections
• Chronic alcoholics are at increased risk of hepatotoxicity from acetaminophen so it should not be taken more than 2 gm per day. Normal person can tolerate up to 4 gm of acetaminophen per day.

Surgical Treatment

If liver damage is irreversible, definitive treatment is a liver transplant in those who have shown a commitment to continued alcohol abstinence.Specific Treatment of Alcoholic Hepatitis (as adapted from the chapter on Hepatitis, Alcoholic)

Abstinence, along with adequate nutritional support, remains the cornerstone of management of patients with alcoholic hepatitis. An addiction specialist could help individualize and enhance the support required for abstinence. About 10% to 20% of patients with alcoholic hepatitis are likely to progress to cirrhosis annually, and 10% of the individuals with alcoholic hepatitis have a regression of liver injury with abstinence.

Patients with alcoholic hepatitis subdivide into mild-moderate alcoholic hepatitis or severe alcoholic hepatitis. A DF (discriminant function) is calculated as 4.6 * (patient's prothrombin time - control prothrombin time) + total bilirubin of patient. MELD score is calculated as a 3.8*loge(serum bilirubin [mg/dL]) + 11.2*loge(INR) + 9.6*loge(serum creatinine [mg/dL]) + 6.4.  Patients with severe alcoholic hepatitis with or without hepatic encephalopathy are considered candidates for a short course of prednisolone (40 mg/day for 28 days). Prednisolone is preferred to prednisone as it does not require metabolism in the liver for its therapeutic efficacy. For patients unable to take it orally, methylprednisolone, 32 mg intravenously daily, is an option. However, failure to respond to steroids within a week evident by a Lille score of greater than 0.45 indicates a lack of response to steroids which should then be discontinued. For patients with a Lille score of less than 0.45 (Lille responders), prednisolone should continue for another three weeks. Glucocorticoids alter the expression of anti-inflammatory genes, thus promoting its anti-inflammatory role. Contraindications to steroid use include any active gastrointestinal (GI) bleeding, severe pancreatitis, uncontrolled diabetes, active infection, or renal failure. Such patients may receive pentoxifylline (400 mg orally, three times a day for 28 days). Hepatorenal syndrome is one of the leading causes of death in patients with alcoholic hepatitis. Patients with acute kidney injury or hepatorenal syndrome respond poorly to corticosteroid therapy. Patients with bacterial infection may be treated with corticosteroids after the infection is under control with antibiotics. Response to prednisolone is graded as complete if Lille score is less than 0.16, partial if Lille score is between 0.16 and 0.56), or null if Lille score is greater than 0.56. A Lille score of more than 0.45 after one week of corticosteroid therapy is associated with 75% mortality at 6 months.[4]

Many recent trials, including the STOPAH trial and meta-analysis of the use of steroids and pentoxifylline, reveal only short-term (28-day) mortality improvements with steroids, no difference of 6-month, or 1-year mortality with steroid therapy and no benefit with the use of Pentoxifylline. In STOPAH trial, however, patients with less severe alcoholic hepatitis were included, and most patients recruited had a clinical diagnosis of alcoholic hepatitis. Thus it is possible that patients with decompensated alcoholic cirrhosis may have received a diagnosis of alcoholic hepatitis, which significantly alters the result of the trial. Also, patients with renal dysfunction met the exclusion criteria for the trial which might have biased the results against the use of pentoxifylline as the previously reported benefits of pentoxifylline were because of the prevention or regression of hepatorenal syndrome. Attempted therapy with anti-TNF (tumor necrosis factor) agents like infliximab and etanercept demonstrate no proven survival benefits. Anti-TNF agents may even increase the incidence of infections and death.[5]

Patients with alcoholic hepatitis are prone to infections, especially when on steroids; this is particularly important as it might lead to a poor prognosis, acute renal injury, and multi-organ dysfunction. Patients with alcoholic hepatitis are at risk of alcohol withdrawal. Lorazepam and oxazepam are the preferred benzodiazepines for prophylaxis and treatment of alcohol withdrawal. Documentation of daily caloric intake is necessary for patients with alcoholic hepatitis, and nutritional supplementation (preferably by mouth or nasogastric tube) is an option if oral intake is less than 1200 kcal in a day.

Liver transplantation could be a consideration for patients not responsive to steroids and with a MELD of greater than 26. However, varied barriers, including fear of recidivism, organ shortage, and social and ethical considerations, exist. A survey of liver transplant programs conducted in 2015 revealed only 27% of the programs offering a transplant to alcoholic hepatitis patients. Out of the 3290 liver transplants performed, 1.37% were on alcoholic hepatitis patients. The six months, one year and 5-year survival was 93%, 93%, and 87% respectively, the outcomes of which are comparable to patients with similar MELD scores. The recidivism rates are similar (17%) to patients transplanted for alcohol-related cirrhosis.

Nursing Management

• Assess nutritional status- many alcoholics have a poor diet that lacks essential nutrients
• Assess the intake of alcohol intake using the CAGE tool
• Assess body weight, weigh patient daily as fluid retention is common
• Measure abdomen girth as some may develop ascites
• Assess liver function enzymes
• Encourage patient to join AA
• Encourage patient to abstain from alcohol
• Avoid all medications that can affect the liver negatively
• Encourage a healthy diet
• Check coagulation profile as liver disease may prolong INR
• Assess mental status as liver disease can cause encephalopathy
• Encourage patient to stop smoking

When To Seek Help

• Confusion
• Prolonged INR
• Unstable hemodynamics
• Bleeding
• Ascites

Outcome Identification

Prognosis at the early stage is good since steatosis or steatohepatitis lesions may be reversible after alcohol withdrawal. In the stage of cirrhosis, the lesions are irreversible, and the prognosis becomes poor. Screening for hepatocellular carcinoma at this stage is imperative. Patients with a DF greater than 32 and MELD score higher than 20 predicts higher mortality with a diagnosis of severe alcoholic hepatitis. Critically ill patient has a 30-day mortality rate of more than 50%. The presence of ascites, variceal bleeding, severe encephalopathy, and hepatorenal syndrome indicates poor prognosis.

Coordination of Care

All health professionals must coordinate their actions to improve the management of the patient with severe alcohol addiction, which is responsible for alcoholic liver disease. More than for other pathologies, psychologists and psychiatrists must be asked by clinicians to assess the psychological state of patients to determine the origin of alcohol intoxication (depression, post-traumatic shock).

A physician psychosocial belief questionnaire and a 3-day residential communication skills course increase interviewing styles. [Level 2]

Coordination starts with excellent communication between nurses, doctors, pharmacists, dietitians, psychologists, and rehab personnel. In the case of hospitalization of the patients, the prescriptions of the doctors can be discussed with the nurses, as regards the indications for the realization in practice, in a cooperative atmosphere. This communication could take place at the patient's bedside during visits or in staff meetings. Collaborative communication is associated with a positive patient, nurse, and physician outcomes. Pharmacists can be consulted for medication therapy to guide the patient through the detoxification stage, performing mediation therapy management, medication reconciliation, and verifying dosing, and reporting any concerns to the healthcare team. Nursing is on the front lines to assess the effectiveness of care during inpatient therapy. Psychological professionals must make this evaluation during any rehabilitative treatment, whether in or outpatient. A nutritionist or dietician should have input to bring about optimal caloric and nutrient intake. All members of the team need to evaluate abstinence compliance and report their findings to the rest of the interprofessional team.

All the staff must maintain medical confidentiality.

The literature proposes several interventions have designed to improve the care delivered to the patient in terms of rapid recovery, the stability of health patient safety (compensated cirrhosis) and the performance of the patient.

The introducing video conferencing during the postoperative period ("telerounds") is associated with increased patient satisfaction and may decrease the routine during hospitalization of patients, especially if it is prolonged.[6] [Level 2]

It is crucial to assess the degree of satisfaction of physicians (gastroenterologists and surgeons) and all paramedical staff (nurses, secretaries) in their work environment to propose innovative activities that meet their expectations and target problems that are solvable with short-term interventions.[7] [Level 3]

 Repeated collection of staff and patient satisfaction data through a questionnaire could contribute to the implementation of work improvement measures in the short and medium-term. [Level 5] Video projections for staff and patients showing proper practice techniques (handwashing, ascites punctures, etc.) could reduce stress and reduce some of the problems inherent in patient management.[8] [Level 5]

Alcoholic liver disease requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, psychological/rehab personnel, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V] Addressing the underlying misuse of alcohol is the primary objective.

Health Teaching and Health Promotion

Outside medical treatment, patient education is the key to treatment for patients with alcoholic liver disease.

Absolute abstinence from alcohol is crucial for preventing disease progression and complications. Sobriety is difficult to achieve without a rehabilitative program run by specialized staff. Psychological care is needed to act on the causes of alcohol addiction, and this may require the help of the patient's family

It's important to encourage patients with alcoholic liver disease to participate in counseling programs and psychological assistance group.

The education component also concerns the need to convince the patient to follow a screening program (to detect hepatocellular carcinoma) in case of severe liver damage.

Risk Management

Following are major complication of alcoholic liver disease:

• Variceal Hemorrhage: Patient presents with hematemesis or melena. Treatment options include endoscopic band ligation, sclerotherapy, and placement of transjugular intrahepatic portosystemic shunt placement (TIPS). TIPS increases the risk of hepatic encephalopathy.
• Ascites: This is the most common complication of alcoholic liver disease where there is an accumulation of fluid within the peritoneal cavity. The patient usually presents with abdominal swelling and pedal edema. Treatment options are sodium restriction, diuretics, paracentesis, and TIPS.
• Spontaneous Bacterial Peritonitis(SBP): It is an infection of ascitic fluid without evidence of any other intraabdominal source (e.g. perforated viscus) of infection. The diagnosis is established by positive ascitic fluid bacterial culture or ascitic fluid absolute neutrophil count of >250/mm3. Cefotaxime is preferred antibiotic but ciprofloxacin can be used if the patient is not able to take cefotaxime. 
• Hepatorenal syndrome: It is the development of renal failure due to advanced alcoholic liver disease where other causes of renal failure are excluded. It is characterized by a progressive rise in creatinine, low sodium excretion rate, oliguria, benign urinary sediment and absence of proteinuria. Type 1 hepatorenal syndrome is a more serious type with at least two-fold increase in creatinine in less than two weeks. It is associated with a high mortality rate. Type 2 is slower in onset and has a relatively better prognosis. Treatment for critically ill patient includes norepinephrine and albumin. For noncritically ill patient treatment includes midodrine ( oral alpha agonist), octreotide, and albumin. Ultimate treatment is liver transplantation
• Hepatic hydrothorax: It is the presence of pleural effusion and other causes of pleural effusion are excluded. Treatment is diuretics, thoracentesis, and TIPS.
• Hepatopulmonary syndrome: It is characterized by the presence of elevated alveolar-arterial oxygen gradient on room air and evidence of intrapulmonary vascular abnormalities. The patient usually presents with shortness of breath and hypoxia.. There is no treatment option except liver transplantation.
• Hepatic encephalopathy: It characterized by reversible neuropsychiatric abnormalities. Treatment includes lactulose, rifaximin and correction of precipitating factors like infection, GI bleeding, etc.
• Other rare complications are cirrhotic cardiomyopathy, hepatocellular carcinoma, portal gastropathy, portopulmonary hypertension, and portal vein thrombosis.