Diagnosis of alcoholic liver disease

Table 1 Typical clinical features of alcoholic liver disease[36-40]

Spectrum of ALD	Clinical presentation
Alcoholic fatty liver	Asymptomatic
Alcoholic hepatitis	Jaundice
	Anorexia
	Fever
	+/- RUQ/epigastric pain
	+/- Abdominal distention due to ascites
	+/- Proximal muscle weakness
	+/- Confusion due to HE
Compensated cirrhosis	Asymptomatic
	Anorexia
	Weight loss
	Weakness
	Fatigue
	Muscle cramps
	Amenorrhea or irregular menses
	Impotence, infertility, loss of sexual drive
Decompensated cirrhosis	Jaundice
	Pruritus
	GI bleeding
	Weight gain
	Abdominal distention due to ascites
	Lower extremity edema
	Easy bruising
	Sleep disturbances
	Confusion

ALD: Alcoholic liver disease; GI: Gastrointestinal; RUQ: Right upper quadrant; HE: Hepatic encephalopathy.

Table 2 Alcohol use disorders identification test[46]

1 How often do you have on a drink containing alcohol?

(0) Never (skip to questions 9-10)

(1) Monthly or less

(2) 2 to 4 times a month

(3) 2 to 3 times a week

(4) 4 or more times a week

2 How many drinks containing alcohol do you have on a typical day when you are drinking?

(0) 1 or 2

(1) 3 or 4

(2) 5 or 6

(3) 7, 8, or 9

(4) 10 or more

3 How often do you have six or more drinks on one occasion?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

4 How often during the last year have you found that you were not able to stop drinking once you had started?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

5 How often during the last year have you failed to do what was normally expected from you because of drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

6 How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

7 How often during the last year have you had a feeling of guilt or remorse after drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

8 How often during the last year have you been unable to remember what happened the night before because you had been drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

9 Have you or someone else been injured as a result of your drinking?

(0) No

(2) Yes, but not in the last year

(4) Yes, during the last year

10 Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?

(0) No

(2) Yes, but not in the last year

(4) Yes, during the last year

Skip to questions 9 and 10 if total score for questions 2 and 3 = 0.

Table 3 Brief screening tests for alcohol use disorders[44,48]

Test	Questions	Scoring	Positive result
AUDIT-C	Q1: How often did you have a drink containing alcohol in the past year?		For women ≥ 3 points; for men ≥ 4 points
	Never	0 points
	Monthly or less	1 point
	Two to four times a month	2 points
	Two to three times per week	3 points
	Four or more times a week	4 points
	Q2: How many drinks did you have on a typical day when you were drinking in the past year?
	One or two	0 points
	Three or four	1 point
	Five or six	2 points
	Seven to nine	3 points
	Ten or more	4 points
	Q3: How often did you have six or more drinks on one occasion in the past year?
	Never	0 points
	Less than monthly	1 point
	Monthly	2 points
	Weekly	3 points
	Daily or almost daily	4 points
Single question screening test from NIAAA	How many times in the past year have you had five (four for women) or more drinks in a day?	One point per time	≥ 1 time
Three question screening test from NIAA	Q1: On average, how many days per week do you drink alcohol? Q2: On a typical day when you drink, how many drinks do you have? Q3: What is the maximum number of drinks you had on any given occasion during the past month		For men, > 14 drinks per week or > 4 drinks per occasion; for women or person older than 65 years, > 7 drinks per week or > 3 drinks per occasion

AUDIT-C: Alcohol use disorders identification test-consumption; NIAAA: National Institute on Alcohol Abuse and Alcoholism.

Table 4 Physical findings in alcoholic liver disease[58-67]

Spectrum of ALD	Physical examination findings
Fatty liver	Normal examination
	+/- Hepatomegaly
Alcoholic hepatitis	Jaundice
	Tender hepatomegaly
	+/- Ascites
	+/- Hepatic bruit
	Proximal muscle wasting
	Decreased grip strength
	+/- Hepatic encephalopathy (confusion, asterixis, hippus)
Cirrhosis	Spider angiomata (face, trunk, upper extremities)
	Parotid gland enlargement
	+/- Fetor hepaticus
	Gynecomastia
	+/- Hepatomegaly
	Firm liver edge with nodular contour
	+/- Splenomegaly
	Caput medusa (abdominal wall collaterals)
	Cruveilhier-Baumgarten murmur
	Testicular atrophy
	Palmar erythema
	Digital clubbing
	Muehrcke nails (paired horizontal white bands)
	Terry nails (large white proximal nail bed)
	Hypertrophic osteoarthropathy
	Dupuytren’s contracture
Decompensated cirrhosis	Cirrhotic physical finding plus:
	Jaundice
	Ascites
	Peripheral edema
	Hepatic encephalopathy (confusion, asterixis, hippus)

ALD: Alcoholic liver disease.

Table 5 Sensitivity and specificity of biomarkers in detecting harmful or heavy alcohol consumption[105-107]

Biomarker	AST	ALT	MCV	CDT	CDT + GGT	CDT + GGT + MCV
Sensitivity	47%-68%	32%-50%	45%-48%	63%-84%	83%-90%	88%
Specificity	80%-95%	87%-92%	52%-94%	92%-98%	95%-98%	95%

AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; MCV: Mean corpuscular volume; CDT: Carbohydrate-deficient transferring; GGT: Gamma-glutamyltranspeptidase.