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Alcoholic Liver Disease
Wide spectrum of disease ranging from subclinical to end-stage liver disease
∼ 20-40% of chronic alcoholics who undergo biopsy have histologic evidence of alcoholic liver disease (ALD)
Clinical Issues
• Very variable presentation
• Moderately elevated transaminases (AST/ALT ratio typically >2)
Microscopic
• Combination of hepatocyte injury, inflammation, steatosis, and fibrosis
Hepatocytic ballooning
Lobular inflammation with predominance of neutrophils
Mallory-Denk bodies (Mallory hyaline)
Megamitochondria
Steatosis
Fibrosis
– Most often pericellular and perivenular, especially initially
• Cholestatic features may be seen
• Iron deposition in hepatocytes and Kupffer cells is common
Top Differential Diagnoses
• Nonalcoholic steatohepatitis (NASH)
Histology of ALD and NASH virtually identical; favor ALD when Mallory bodies, neutrophil aggregates, or sclerosing hyaline necrosis is present
• Chronic hepatitis C
Many patients have both ALD and hepatitis C infection
Gross AppearanceThis explant from a patient with end-stage alcohol-induced cirrhosis shows a brown, tan, fibrotic, and nodular cut surface.
SteatosisSteatosis, most often macrovesicular (large droplets of fat within the hepatocytes that commonly push the nuclei to the periphery of the cytoplasm), is a typical finding in alcoholic liver disease (ALD).
Hepatocyte BallooningThis high-magnification photomicrograph shows ballooned hepatocytes with rarefied, clumped cytoplasm and Mallory-Denk bodies typical of alcoholic steatohepatitis.
Mallory-Denk BodiesBallooned hepatocytes containing many Mallory-Denk bodies are typical in alcoholic steatohepatitis, along with lobular inflammation featuring satellitosis of neutrophils around the ballooned cells.
TERMINOLOGY
Abbreviations
• Alcoholic liver disease (ALD)
Definitions
• Hepatocyte injury and inflammation resulting from chronic alcohol consumption
Wide spectrum of clinical and pathologic disease ranging from mild/subclinical to end-stage cirrhosis and death
ETIOLOGY/PATHOGENESIS
Alcohol Consumption
• Alcohol is direct hepatotoxin
• Both genetic and environmental factors determine susceptibility to liver injury
CLINICAL ISSUES
Epidemiology
• Incidence
∼ 20-40% of chronic alcoholics who undergo biopsy have histologic evidence of ALD
∼ 20-40% of chronic alcoholics who undergo biopsy have histologic evidence of alcoholic liver disease (ALD)
with rarefied, clumped cytoplasm and Mallory-Denk bodies 
typical of alcoholic steatohepatitis.
containing many Mallory-Denk bodies are typical in alcoholic steatohepatitis, along with lobular inflammation featuring satellitosis of neutrophils around the ballooned cells.
