UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

酒精性脂肪性肝病和酒精性肝硬化的临床表现和诊断

Author
Scott L Friedman, MD
Section Editor
Bruce A Runyon, MD
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF
Translators
钟碧慧, 主任医师，教授

引言

过量饮酒与一系列肝脏表现有关，包括酒精性脂肪性肝病(伴或不伴脂肪性肝炎)、酒精性肝炎和肝硬化。酒精摄入量大于等于30g/d(一标准杯含14g酒精(图 1))的患者发生肝硬化的风险增高，但大部分患者即使大量饮酒也不会发生肝硬化(饮酒30-60g/d者的时点患病率为1%，饮酒120g/d者的时点患病率为6%)[1]。不幸的是，在的确出现了肝病的患者中，通常在已经发生严重且危及生命的肝病后才会出现症状。

本专题将总结酒精性脂肪性肝病和酒精性肝硬化的临床表现和诊断。酒精性肝病的处理和发病机制，以及酒精性肝炎患者的处理方法将单独讨论。 (参见“酒精性脂肪肝和酒精性肝硬化的预后和管理”和“成人肝硬化：并发症、一般治疗和预后的概述”和“酒精性肝病的发病机制”和“酒精性肝炎：临床表现及诊断”和“酒精性肝炎：自然病程和治疗”和“肝移植治疗酒精性肝病”)

2010年，美国肝病研究协会和美国胃肠病学会发布了一项有关酒精性肝病患者评估和处理的联合指南(joint guideline)[2]。2012年，欧洲肝脏研究协会发布了另一项指南(guideline)[3]。以下讨论内容与这些指南基本一致。

流行病学

酗酒在全世界都很常见；据估计，美国成年人的终生患病率为18%。在2010年，估计有493,300例死亡(占所有死亡人数的1%)由酒精性肝硬化导致[4]。据美国国立卫生研究院估计，2009年有超过31,000例患者死于肝硬化，其中酒精性肝硬化所致死亡占48%(年龄调整死亡率为4.5例死亡/100,000人)[5]。 (参见“酒精使用障碍：流行病学、发病机制、临床表现、不良后果和诊断”)

人均饮酒量较高的地区相较于人均饮酒量水平较低的地区，前者酒精性肝病的患病率更高。饮酒率和酒精性肝病患病率较高的地区包括：欧洲东部、欧洲南部和英国[6]。酒精性肝病造成的影响越来越大，对这种情况的警惕使得英国启动了全国性的响应以处理这种危机[7]。而穆斯林人口数量较多的国家的饮酒率和酒精性肝病患病率最低。美国的饮酒水平介于中间(美国成人的饮酒量为每人每年9.4L；在英国为13.4L；在印度尼西亚则为0.6L)。

                             

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-12-15.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Bellentani S, Saccoccio G, Costa G, et al. Drinking habits as cofactors of risk for alcohol induced liver damage. The Dionysos Study Group. Gut 1997; 41:845.
  2. O'Shea RS, Dasarathy S, McCullough AJ, et al. Alcoholic liver disease. Hepatology 2010; 51:307.
  3. European Association for the Study of Liver. EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012; 57:399.
  4. Rehm J, Samokhvalov AV, Shield KD. Global burden of alcoholic liver diseases. J Hepatol 2013; 59:160.
  5. http://pubs.niaaa.nih.gov/publications/Surveillance93/Cirr09.htm (Accessed on November 28, 2012).
  6. http://www.who.int/substance_abuse/publications/global_alcohol_report/en/ (Accessed on November 28, 2012).
  7. Williams R, Aspinall R, Bellis M, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384:1953.
  8. Edmondson HA, Peters RL, Frankel HH, Borowsky S. The early stage of liver injury in the alcoholic. Medicine (Baltimore) 1967; 46:119.
  9. Naveau S, Giraud V, Borotto E, et al. Excess weight risk factor for alcoholic liver disease. Hepatology 1997; 25:108.
  10. Crabb DW. Pathogenesis of alcoholic liver disease: newer mechanisms of injury. Keio J Med 1999; 48:184.
  11. Lane BP, Lieber CS. Ultrastructural alterations in human hepatocytes following ingestion of ethanol with adequate diets. Am J Pathol 1966; 49:593.
  12. Tang-Barton P, Vas W, Weissman J, et al. Focal fatty liver lesions in alcoholic liver disease: a broadened spectrum of CT appearances. Gastrointest Radiol 1985; 10:133.
  13. Barrio E, Tomé S, Rodríguez I, et al. Liver disease in heavy drinkers with and without alcohol withdrawal syndrome. Alcohol Clin Exp Res 2004; 28:131.
  14. Deleuran T, Grønbaek H, Vilstrup H, Jepsen P. Cirrhosis and mortality risks of biopsy-verified alcoholic pure steatosis and steatohepatitis: a nationwide registry-based study. Aliment Pharmacol Ther 2012; 35:1336.
  15. Parés A, Caballería J, Bruguera M, et al. Histological course of alcoholic hepatitis. Influence of abstinence, sex and extent of hepatic damage. J Hepatol 1986; 2:33.
  16. Galambos JT. Natural history of alcoholic hepatitis. 3. Histological changes. Gastroenterology 1972; 63:1026.
  17. Alexander JF, Lischner MW, Galambos JT. Natural history of alcoholic hepatitis. II. The long-term prognosis. Am J Gastroenterol 1971; 56:515.
  18. Bird GL, Williams R. Factors determining cirrhosis in alcoholic liver disease. Mol Aspects Med 1988; 10:97.
  19. Gao B, Bataller R. Alcoholic liver disease: pathogenesis and new therapeutic targets. Gastroenterology 2011; 141:1572.
  20. Jepsen P, Ott P, Andersen PK, et al. Clinical course of alcoholic liver cirrhosis: a Danish population-based cohort study. Hepatology 2010; 51:1675.
  21. Adachi M, Brenner DA. Clinical syndromes of alcoholic liver disease. Dig Dis 2005; 23:255.
  22. Galambos JT. Alcoholic hepatitis: its therapy and prognosis. Prog Liver Dis 1972; 4:567.
  23. Morgan MY. The prognosis and outcome of alcoholic liver disease. Alcohol Alcohol Suppl 1994; 2:335.
  24. Diehl AM. Liver disease in alcohol abusers: clinical perspective. Alcohol 2002; 27:7.
  25. Orr JG, Homer T, Ternent L, et al. Health related quality of life in people with advanced chronic liver disease. J Hepatol 2014; 61:1158.
  26. Kazemi-Shirazi L, Veloso MP, Frommlet F, et al. Differentiation of nonalcoholic from alcoholic steatohepatitis: are routine laboratory markers useful? Wien Klin Wochenschr 2008; 120:25.
  27. Morita Y, Ueno T, Sasaki N, et al. Comparison of liver histology between patients with non-alcoholic steatohepatitis and patients with alcoholic steatohepatitis in Japan. Alcohol Clin Exp Res 2005; 29:277S.
  28. Sorbi D, Boynton J, Lindor KD. The ratio of aspartate aminotransferase to alanine aminotransferase: potential value in differentiating nonalcoholic steatohepatitis from alcoholic liver disease. Am J Gastroenterol 1999; 94:1018.
  29. Nyblom H, Berggren U, Balldin J, Olsson R. High AST/ALT ratio may indicate advanced alcoholic liver disease rather than heavy drinking. Alcohol Alcohol 2004; 39:336.
  30. Diehl AM, Potter J, Boitnott J, et al. Relationship between pyridoxal 5'-phosphate deficiency and aminotransferase levels in alcoholic hepatitis. Gastroenterology 1984; 86:632.
  31. Singh DK, Rastogi A, Sakhuja P, et al. Comparison of clinical, biochemical and histological features of alcoholic steatohepatitis and non-alcoholic steatohepatitis in Asian Indian patients. Indian J Pathol Microbiol 2010; 53:408.
  32. Cohen JA, Kaplan MM. The SGOT/SGPT ratio--an indicator of alcoholic liver disease. Dig Dis Sci 1979; 24:835.
  33. Moussavian SN, Becker RC, Piepmeyer JL, et al. Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease. Dig Dis Sci 1985; 30:211.
  34. Das SK, Mukherjee S, Vasudevan DM, Balakrishnan V. Comparison of haematological parameters in patients with non-alcoholic fatty liver disease and alcoholic liver disease. Singapore Med J 2011; 52:175.
  35. Van Ness MM, Diehl AM. Is liver biopsy useful in the evaluation of patients with chronically elevated liver enzymes? Ann Intern Med 1989; 111:473.
  36. Liangpunsakul S, Chalasani N. What should we recommend to our patients with NAFLD regarding alcohol use? Am J Gastroenterol 2012; 107:976.
  37. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology 2012; 142:1592.
  38. Lee M, Kowdley KV. Alcohol's effect on other chronic liver diseases. Clin Liver Dis 2012; 16:827.
  39. Chapman RW, Morgan MY, Laulicht M, et al. Hepatic iron stores and markers of iron overload in alcoholics and patients with idiopathic hemochromatosis. Dig Dis Sci 1982; 27:909.
  40. Palmentieri B, de Sio I, La Mura V, et al. The role of bright liver echo pattern on ultrasound B-mode examination in the diagnosis of liver steatosis. Dig Liver Dis 2006; 38:485.
  41. Saverymuttu SH, Joseph AE, Maxwell JD. Ultrasound scanning in the detection of hepatic fibrosis and steatosis. Br Med J (Clin Res Ed) 1986; 292:13.
  42. Mathiesen UL, Franzén LE, Aselius H, et al. Increased liver echogenicity at ultrasound examination reflects degree of steatosis but not of fibrosis in asymptomatic patients with mild/moderate abnormalities of liver transaminases. Dig Liver Dis 2002; 34:516.
  43. Mortele KJ, Ros PR. Imaging of diffuse liver disease. Semin Liver Dis 2001; 21:195.
  44. Rofsky NM, Fleishaker H. CT and MRI of diffuse liver disease. Semin Ultrasound CT MR 1995; 16:16.
  45. Borra RJ, Salo S, Dean K, et al. Nonalcoholic fatty liver disease: rapid evaluation of liver fat content with in-phase and out-of-phase MR imaging. Radiology 2009; 250:130.
  46. Okazaki H, Ito K, Fujita T, et al. Discrimination of alcoholic from virus-induced cirrhosis on MR imaging. AJR Am J Roentgenol 2000; 175:1677.
  47. Machann J, Thamer C, Stefan N, et al. Follow-up whole-body assessment of adipose tissue compartments during a lifestyle intervention in a large cohort at increased risk for type 2 diabetes. Radiology 2010; 257:353.
  48. Longo R, Pollesello P, Ricci C, et al. Proton MR spectroscopy in quantitative in vivo determination of fat content in human liver steatosis. J Magn Reson Imaging 1995; 5:281.
  49. Schlemmer HP, Sawatzki T, Sammet S, et al. Hepatic phospholipids in alcoholic liver disease assessed by proton-decoupled 31P magnetic resonance spectroscopy. J Hepatol 2005; 42:752.
  50. Menon DK, Sargentoni J, Taylor-Robinson SD, et al. Effect of functional grade and etiology on in vivo hepatic phosphorus-31 magnetic resonance spectroscopy in cirrhosis: biochemical basis of spectral appearances. Hepatology 1995; 21:417.
  51. Rubin E, Lieber CS. Alcohol-induced hepatic injury in nonalcoholic volunteers. N Engl J Med 1968; 278:869.
  52. Lefkowitch JH. Morphology of alcoholic liver disease. Clin Liver Dis 2005; 9:37.
  53. Christoffersen P, Braendstrup O, Juhl E, Poulsen H. Lipogranulomas in human liver biopsies with fatty change. A morphological, biochemical and clinical investigation. Acta Pathol Microbiol Scand A 1971; 79:150.
  54. Denk H, Lackinger E. Cytoskeleton in liver diseases. Semin Liver Dis 1986; 6:199.
  55. Bacon BR, Farahvash MJ, Janney CG, Neuschwander-Tetri BA. Nonalcoholic steatohepatitis: an expanded clinical entity. Gastroenterology 1994; 107:1103.
  56. French SW, Nash J, Shitabata P, et al. Pathology of alcoholic liver disease. VA Cooperative Study Group 119. Semin Liver Dis 1993; 13:154.
  57. Teli MR, Day CP, Burt AD, et al. Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver. Lancet 1995; 346:987.
  58. Worner TM, Lieber CS. Perivenular fibrosis as precursor lesion of cirrhosis. JAMA 1985; 254:627.
  59. Nakano M, Worner TM, Lieber CS. Perivenular fibrosis in alcoholic liver injury: ultrastructure and histologic progression. Gastroenterology 1982; 83:777.
  60. Pomier-Layrargues G, Kusielewicz D, Willems B, et al. Presinusoidal portal hypertension in non-alcoholic cirrhosis. Hepatology 1985; 5:415.
  61. Fauerholdt L, Schlichting P, Christensen E, et al. Conversion of micronodular cirrhosis into macronodular cirrhosis. Hepatology 1983; 3:928.
  62. Hautekeete ML, Degott C, Benhamou JP. Microvesicular steatosis of the liver. Acta Clin Belg 1990; 45:311.
  63. Powell EE, Cooksley WG, Hanson R, et al. The natural history of nonalcoholic steatohepatitis: a follow-up study of forty-two patients for up to 21 years. Hepatology 1990; 11:74.
  64. Yeh MM, Brunt EM. Pathology of nonalcoholic fatty liver disease. Am J Clin Pathol 2007; 128:837.
  65. Dunn W, Angulo P, Sanderson S, et al. Utility of a new model to diagnose an alcohol basis for steatohepatitis. Gastroenterology 2006; 131:1057.