Let's begin our next case.
A 67-year-old woman is
seen in clinic for a routine visit.
She feels well, her only past
medical history is hypertension.
She drinks 6 cans of beer per night.
She recently traveled to Mexico
but has not had any diarrhea.
Her vitals are normal.
She has mild hepatomegaly on physical exam.
Lab studies are shown here:
So her ALT is 85 (U/L), AST is 180
(U/L) and her bilirubin is 0.8 (mg/dL).
What is the most likely diagnosis?
So let's point out that she
has an alcohol use disorder.
She has recent travel to Mexico which does
raise some suspicion for hepatitis A or E
but notably, she has no symptoms
of either of these diseases.
And she has this AST to ALT
ratio of greater than 2 to 1.
We'll discuss what
that means in a bit.
So, let's talk now about
alcohol-induced liver disease.
In general, this is just inflammation
of the liver caused by alcohol.
Patients often have a serum AST and ALT elevation
of 2 to 6 times the upper limit of normal.
The typical ratio is an AST to
ALT ratio of 2 to 1 or greater.
Patients may be either
asymptomatic with just fatty liver
or they may be symptomatic and
develop alcoholic hepatitis.
So here on the right you can see the
natural progression of this disease.
You begin with a normal liver.
With recurrent alcohol use,
you develop fatty liver or steatosis
With ongoing use, you can develop
inflammation, so steatohepatitis.
This can then progress to fibrosis, cirrhosis and
lastly, the dreaded hepatocellular carcinoma.
So, patients with this disease may present
with jaundice, a loss of appetite or anorexia
and they may also have
The treatment depends on the
severity of their disease.
So if it is mild, you just do supportive care and
counsel them to remain abstinent from alcohol.
If their disease is moderate to severe with
inflammation, you could consider prednisone.
So, let's return to our case.
We have a 67-year-old woman
with an alcohol use disorder,
a recent travel to Mexico but no
symptoms of hepatitis A or E
and she has an AST to ALT
ratio of greater than 2 to 1
and both of these tests are somewhat abnormal
within the 2 to 6 times the upper limit of normal.
So this ratio with our clinical picture should
prompt you to think of alcoholic liver disease.
She is asymptomatic so she likely
just has alcoholic steatohepatitis
and she should be counseled
for her alcohol use disorder.