STEPTRACKERGASTROINTESTINAL | PATHOLOGY + PHYSIOLOGY + ANATOMY | HIGH-YIELD REVIEW

Alcoholic & Fatty Liver Disease, Cirrhosis

From fat to fibrosis — and every consequence of a scarred liver and high portal pressure.

FOCUS ON
Alcohol: steatosis (reversible) → hepatitis (Mallory-Denk bodies, neutrophils, AST:ALT > 2) → cirrhosis (micronodular). NAFLD = metabolic syndrome, ALT > AST. Cirrhosis = bridging fibrosis + regenerative nodules (stellate cells). Portal hypertension → varices, ascites (SAAG ≥ 1.1), splenomegaly, SBP, hepatorenal syndrome.
CONDITION
MECHANISM
FEATURES
CLUE · TREATMENT
Alcoholic steatosis
Ethanol → ↑ NADH → ↑ fatty acid synthesis, ↓ β-oxidation; ↓ lipoprotein export
Macrovesicular fat, hepatomegaly; mild enzyme rise
Reversible with abstinence
Alcoholic hepatitis
Acetaldehyde and ROS injure hepatocytes
Ballooned hepatocytes, Mallory-Denk bodies (cytokeratin aggregates), neutrophils; fever, tender hepatomegaly, jaundice
AST:ALT > 2 · steroids if severe
NAFLD / MASLD
Insulin resistance → fat accumulates → steatohepatitis (NASH) → fibrosis
Obesity, diabetes, dyslipidemia; usually silent; ALT > AST
Leading cause of chronic liver disease · weight loss
Cirrhosis
Chronic injury → stellate (Ito) cells in the space of Disse become myofibroblasts (TGF-β) → collagen
Diffuse bridging fibrosis + regenerative nodules; shrunken nodular liver
Alcohol → micronodular · viral → macronodular · ↑ HCC risk
Portal hypertension
Pre-hepatic (portal vein thrombosis), intrahepatic (cirrhosis, schistosomiasis), post-hepatic (Budd-Chiari, right heart failure)
Varices, caput medusae, splenomegaly → thrombocytopenia, ascites
Nonselective β-blocker · TIPS (↑ encephalopathy)
Ascites
Portal pressure + low albumin + RAAS activation → Na⁺ and water retention
Shifting dullness, fluid wave
SAAG ≥ 1.1 → portal hypertension · spironolactone + furosemide, paracentesis
Spontaneous bacterial peritonitis
Gut bacteria translocate into ascites (E coli, Klebsiella)
Fever, abdominal pain, encephalopathy — or silent
Ascitic PMNs ≥ 250/mm³ · ceftriaxone · prophylaxis
Hepatorenal syndrome
Splanchnic vasodilation → renal vasoconstriction (functional)
Rising creatinine, oliguria, FENa < 1%; normal sediment; no response to fluids
Albumin + vasoconstrictor (terlipressin) · transplant
Hepatopulmonary syndrome
Intrapulmonary vasodilation (↑ NO) → shunting
Platypnea (dyspnea upright), orthodeoxia, hypoxemia
Bubble echo: delayed left-sided bubbles
Hyperestrogenism
↓ hepatic clearance of estrogen; ↑ SHBG
Spider angiomas, palmar erythema, gynecomastia, testicular atrophy
Plus coagulopathy, jaundice, asterixis

Mechanism — alcohol to cirrhosis

Ethanol
→
ADH, ALDH, CYP2E1↑ NADH, acetaldehyde, ROS
→
SteatosisReversible
→
HepatitisNecrosis + neutrophils
→
CirrhosisStellate cell fibrosis

High NADH also blocks gluconeogenesis (hypoglycemia) and shifts pyruvate to lactate (lactic acidosis).

Portosystemic anastomoses

SITE
PORTAL ↔ SYSTEMIC
FINDING
Esophagus
Left gastric ↔ esophageal (azygos)
Esophageal varices
Umbilicus
Paraumbilical ↔ superficial epigastric
Caput medusae
Rectum
Superior rectal ↔ middle/inferior rectal
Anorectal varices
Retroperitoneum
Colic ↔ renal, lumbar
Retroperitoneal varices
SAAG
Serum albumin − ascitic albumin. ≥ 1.1 g/dL: cirrhosis, heart failure, Budd-Chiari · < 1.1: peritoneal carcinomatosis, TB, nephrotic syndrome, pancreatitis.

How it's tested

COMMON CONFUSIONAST:ALT > 2 points to alcohol; ALT > AST points to NAFLD or viral hepatitis. Both can show steatohepatitis and Mallory-Denk bodies.
THE TRAPHepatorenal syndrome looks prerenal (FENa < 1%) but does not respond to fluids. The kidneys are normal — they recover after liver transplant.
YOUR APPROACHCause (alcohol, metabolic, viral) → stage (fat, hepatitis, cirrhosis) → complications (bleeding, ascites, infection, kidney, lung, brain, HCC).

If you see… think…

Fever, tender liver, jaundice, AST 300 / ALT 120 in a drinker → alcoholic hepatitis
Eosinophilic cytoplasmic hyaline inclusions in hepatocytes → Mallory-Denk bodies
Obese diabetic with mildly ↑ ALT and fatty liver → NAFLD
Cell type that lays down collagen in cirrhosis → hepatic stellate (Ito) cell
Cirrhotic with fever, abdominal pain, ascitic PMN 400 → SBP
SAAG 1.6 → portal hypertension
Rising creatinine, FENa 0.2%, no response to albumin in cirrhosis → hepatorenal syndrome
Cirrhotic short of breath when sitting up → hepatopulmonary syndrome
Gynecomastia, spider angiomas, palmar erythema → hyperestrogenism of cirrhosis
Dilated veins radiating from the umbilicus → caput medusae