What is the difference between Alcoholic Fatty Liver Disease (AFLD), Alcoholic Hepatitis (AH), and Alcoholic Cirrhosis (AC)?

From the Guidelines

Alcoholic liver disease progresses through three distinct stages: Alcoholic Fatty Liver Disease (AFLD), Alcoholic Hepatitis (AH), and Alcoholic Cirrhosis (AC), each with unique pathological features, reversibility, and clinical presentations. The key differences between these stages lie in their pathology, with AFLD characterized by fat accumulation in liver cells, AH marked by inflammation and liver cell death, and AC defined by widespread fibrosis and permanent structural changes in the liver 1.

Pathological Features and Reversibility

• AFLD is typically asymptomatic and completely reversible with alcohol cessation, as the fat accumulation in liver cells can be resolved once alcohol consumption is stopped 1.
• AH represents the intermediate stage, where ongoing alcohol consumption causes inflammation and liver cell death, and while potentially reversible with abstinence, severe cases can be life-threatening with mortality rates of 30-50% 1.
• AC is the final, irreversible stage where chronic inflammation leads to widespread fibrosis and permanent structural changes in the liver, with symptoms including portal hypertension, ascites, varices, coagulopathy, and hepatic encephalopathy 1.

Clinical Presentation and Management

• The clinical presentation of these stages varies significantly, ranging from asymptomatic in AFLD, to acute symptoms such as jaundice, abdominal pain, fever, and malaise in AH, and chronic liver failure manifestations in AC 1.
• Treatment for all stages begins with complete alcohol abstinence, with additional supportive care and management of complications increasing in complexity as the disease progresses 1.
• The prognosis of patients with AC is evaluated using commonly used scores such as the MELD or the Child-Pugh scores, and the development of clinical complications has a significant impact on outcome, with the factor with the strongest influence on mortality and liver-related outcome being alcohol consumption 1.

Outcome and Mortality

• The mortality rates for patients with AC are high, with a 1-year mortality rate of 49% following ascites and variceal bleeding, and 64% after clinical episodes of hepatic encephalopathy, and the mortality rate at 5,10, and 15 years being 71%, 84%, and 90%, respectively 1.
• Independent predictors of mortality include age and persistent alcohol consumption, highlighting the importance of complete alcohol abstinence in the management of alcoholic liver disease 1.

From the Research

Definition and Differences

• Alcoholic Fatty Liver Disease (AFLD) is a reversible condition characterized by fatty changes in the liver, which can develop into inflammation, fibrosis, and ultimately cirrhosis with continued excessive drinking 2, 3.
• Alcoholic Hepatitis (AH) is an acute hepatic inflammation associated with significant morbidity and mortality, which can occur in patients with steatosis or underlying cirrhosis 4, 3.
• Alcoholic Cirrhosis (AC) is a condition where the liver is severely scarred, often as a result of long-term alcohol abuse, and can lead to liver failure and other complications 2, 4.

Progression and Relationship

• Alcoholic fatty liver is the only noticeable alteration for many years, and it is completely reversible in 2-4 weeks when ethanol intake is stopped 2.
• After about 6 years of chronic abuse, alcoholic hepatitis may develop, and once established, it progresses within weeks or months to cirrhosis if ethanol intake is not discontinued 2.
• The extent of alcohol consumption is of decisive importance for the development of cirrhosis, and the susceptibility to alcohol varies considerably in different individuals 2.

Clinical Features and Diagnosis

• The proportion of persons under 50 years of age is significantly greater with alcoholic hepatitis than cirrhosis 5.
• Mean daily alcohol consumption is clearly lower among those with fatty liver than hepatitis or cirrhosis 5.
• Symptoms and clinical and biochemical findings do not help in differentiating between hepatitis without cirrhotic change and cirrhosis, but certain signs and symptoms are more frequent in cirrhosis and hepatitis than in fatty liver 5.

Treatment and Prognosis

• Prolonged abstinence is the most effective strategy to prevent disease progression, and corticosteroids provide short-term survival benefit in about half of treated patients with severe AH 4.
• Liver transplantation may be considered in selected patients with AH cases who do not respond to medical therapy, and in patients with advanced alcoholic cirrhosis 4.
• The prognosis under abstinence is relatively more favorable in patients with mild or moderately severe hepatitis, but non-icteric forms require closer attention than has been given them so far 5.