Mueller S, Seitz HK, Rausch V. Non-invasive diagnosis of alcoholic liver disease. World J Gastroenterol 2014; 20(40): 14626-14641
Corresponding Author of This Article
Sebastian Mueller, MD, PhD, Professor, Vice Head, Research Director, Department of Internal Medicine, Salem Medical Center, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany. email@example.com
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Sebastian Mueller, Helmut Karl Seitz, Vanessa Rausch
Sebastian Mueller, Helmut Karl Seitz, Department of Internal Medicine, Salem Medical Center, University of Heidelberg, 69121 Heidelberg, Germany
Sebastian Mueller, Helmut Karl Seitz, Vanessa Rausch, Center for Alcohol Research, University of Heidelberg, 69121 Heidelberg, Germany
ORCID number: $[AuthorORCIDs]
Author contributions: Mueller S and Rausch V analyzed the data and wrote the paper; Seitz HK critically revised the paper and added comments.
Correspondence to: Sebastian Mueller, MD, PhD, Professor, Vice Head, Research Director, Department of Internal Medicine, Salem Medical Center, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany. firstname.lastname@example.org
Telephone: +49-6221-483210 Fax: +49-6221-483494
Received: February 10, 2014 Revised: April 30, 2014 Accepted: July 22, 2014 Published online: October 28, 2014
Alcoholic liver disease (ALD) is the most common liver disease in the Western world. For many reasons, it is underestimated and underdiagnosed. An early diagnosis is absolutely essential since it (1) helps to identify patients at genetic risk for ALD; (2) can trigger efficient abstinence namely in non-addicted patients; and (3) initiate screening programs to prevent life-threatening complications such as bleeding from varices, spontaneous bacterial peritonitis or hepatocellular cancer. The two major end points of ALD are alcoholic liver cirrhosis and the rare and clinically-defined alcoholic hepatitis (AH). The prediction and early diagnosis of both entities is still insufficiently solved and usually relies on a combination of laboratory, clinical and imaging findings. It is not widely conceived that conventional screening tools for ALD such as ultrasound imaging or routine laboratory testing can easily overlook ca. 40% of manifest alcoholic liver cirrhosis. Non-invasive methods such as transient elastography (Fibroscan), acoustic radiation force impulse imaging or shear wave elastography have significantly improved the early diagnosis of alcoholic cirrhosis. Present algorithms allow either the exclusion or the exact definition of advanced fibrosis stages in ca. 95% of patients. The correct interpretation of liver stiffness requires a timely abdominal ultrasound and actual transaminase levels. Other non-invasive methods such as controlled attenuation parameter, serum levels of M30 or M65, susceptometry or breath tests are under current evaluation to assess the degree of steatosis, apoptosis and iron overload in these patients. Liver biopsy still remains an important option to rule out comorbidities and to confirm the prognosis namely for patients with AH.
Core tip: This review article summarizes recent advantages in non-invasive assessment of patients with alcoholic liver disease (ALD) such as elastographic techniques (Fibroscan), acoustic radiation force impulse imaging, shear wave elastography or serum marker and highlights future perspectives which may improve the early diagnosis of ALD.
Citation: Mueller S, Seitz HK, Rausch V. Non-invasive diagnosis of alcoholic liver disease. World J Gastroenterol 2014; 20(40): 14626-14641
Alcoholic liver disease (ALD) is, either alone or in association with other comorbidities such as obesity or viral hepatitis, the leading cause of liver disease. The liver is also the most common target organ of chronic alcohol abuse. In Germany and the United States, chronic alcohol consumption is responsible for over 50% of chronic liver diseases. In South Korea, 7%-31% of cirrhosis cases have been addressed to alcohol in a few single center studies. The treatment of ALD causes huge costs for the health care system with nearly $3 billion per year. Considering the sum of death and disability-adjusted life years (DALYs), in Portugal, liver diseases represented the main source of the burden attributable to alcohol with 31.5% of total DALYs, followed by traffic accidents and several types of cancer. At present, China recorded a 40% increase in the annual per capita consumption of alcohol depending on the region and has therefore experienced the highest increase in alcohol associated health problems.
It is difficult to calculate alcohol related deaths because of imprecise or incomplete information about the actual drinking patterns. Moreover, patients with compensated liver cirrhosis have normal laboratory and ultrasound findings in ca. Forty percent and may often die by seemingly non-liver-related complications such as infections (e.g., pneumonia). The consumption of 20 and 30 g of alcohol per day for women and men enhances the risk of developing ALD, respectively. Liver cirrhosis develops in a minority of ca. Fifteen percent of people consuming more than 80 g of ethanol daily clearly indicating the importance of additional genetic factors for disease progression. Approximately 5% of the whole population show high risk drinking behavior in the United States and Germany and similar ca. Seven percent showed heavy alcohol consumption according to the Korean National Health and Nutrition Examination survey 2009. In the global death statistics published in 2010, liver cirrhosis and hepatocellular carcinoma (HCC) are ranked at position 12 and 16 with one third directly attributable to alcohol. Liver cirrhosis accounts for over 170000 deaths per year in Europe and is in the fourth place in the so-called years of life lost statistics. In ALD patients with cirrhosis, HCC is the most common fatal complication ranking straight behind viral hepatitis B and C. Furthermore, in a global perspective HCC has the second highest cancer incidence rate after kidney tumors.
GENERAL DIAGNOSTIC ASPECTS OF ALD
The early and exact diagnosis of ALD and namely of fibrosis/cirrhosis is important since patients receive an explanation for their symptoms and complaints and get the opportunity to control disease progression through change of life style, avoidance of alcohol and other potentially harmful factors such as obesity. Furthermore, ALD should be separated from other comorbidities (e.g., viral hepatitis) or disease modifying factors (e.g., obesity, drugs) to provide detailed prognostic information. After diagnosis, a targeted search for potential complications such as varices or HCC can be started and surveillance intervals e.g., for HCC can be defined. The diagnosis of ALD is complicated by a rather varied clinical presentation, underreporting by patients and the lack of good biomarkers for alcohol consumption. It is therefore routinely underestimated both by physicians and health statistics[11,12]. Therefore, its diagnosis has to rely on a combination of imaging, laboratory, clinical and elastographic findings.
The early detection of severe steatohepatitis and alcoholic cirrhosis is most important for several reasons: it safes lifes, prevents complications and may initiate follow up programs (Figure 1). Most critical and life threatening end points are (1) decompensated alcoholic liver cirrhosis; and (2) the rare and clinically defined alcoholic hepatitis (AH). AH should not be mismatched with the commonly and histologically detectable steatohepatitis (Figure 1). AH patients classically show not very high transaminase levels but rapidly become icteric. Due to the jaundice they are rapidly diagnosed and presented to more specialized units. Nevertheless they show a poor prognosis usually assessed by the Maddrey discrimination function, the Glasgow ASH score or the Lille model. The nature of AH is still poorly understood. In contrast, the slow progression of ALD towards liver cirrhosis can be unnoticed for many years. For these reasons, patients who are sensitive to alcohol-mediated liver damage but diagnosed too late may have an unfavourable outcome. These patients are listed late for transplantation and are at high risk of dying from complications while waiting for a transplant.
Figure 1 Natural course of alcoholic liver disease and major end points.
HCC: Hepatocellular carcinoma.
The increasing use of transient elastography (TE) as novel ultrasound-based technique has significantly improved early diagnosis and follow up. It is a widespread misconception that conventional approaches such as routine imaging studies or blood tests are able to rule out fibrosis/cirrhosis. Our experience on over 364 patients at Salem Medical Center in Heidelberg indicates that approximately 40% of manifest cirrhosis is overlooked by routine ultrasound and lab tests which are clearly seen with elastography or histology (Table 1). Thus, 22.6% with established F3-4 cirrhosis by histology or elastography have normal bilirubin, INR, platelets, spleen size and no signs of liver cirrhosis. If only ultrasound, bilirubin and INR are considered, 43.5% are normal. Although no long-term prognostic studies have been performed on cirrhotic patients solely identified by elastography, they are certainly at an increased risk of developing HCC or complications of portal hypertension.
Table 1 Diagnosis of confirmed advanced fibrosis/cirrhosis (F3-4) (histology, elastography) by conventional clinical parameters (ultrasound, laboratory) from Salem Medical Center (n = 364).
> 1.3 mg/dL
< 150 /nL
> 11.5 cm
Signs of liver cirrhosis
Bilirubin, INR, signs of liver cirrhosis
Bilirubin, INR, platelets, spleen size, signs of liver cirrhosis
The table shows typical findings of fibrosis/cirrhosis as indicated in the ultrasound (spleen size, signs of cirrhosis) or laboratory [bilirubin, international normalized ratio (INR) and platelets] in patients with no or low fibrosis stages (F0-2) vs advanced fibrosis stages (F3-4). In the last two rows, cirrhosis was considered if one of 3 or 5 parameters was pathologic. As an example, ca. 43% of F3-4 cirrhosis are not diagnosed by a combination of bilirubin, INR and ultrasound signs of liver cirrhosis.
In addition, many other non-invasive approaches to detect various stages of ALD are currently under investigation, such as controlled attenuation parameter (CAP) for fatty liver disease, susceptometry to detect cancerogenic hepatic iron accumulation or serum markers of liver damage or apoptosis such as M65 and M30 (Figure 2). Of course, modern imaging techniques are absolutely essential for HCC screening and are continuously improved. Finally, genetic tests e.g., for PNPLA3 mutations are potential options in the near future since such mutations are increasingly recognized as risk factors for cirrhosis progression.
Figure 2 General non-invasive approaches for patients with suspected alcoholic liver disease.
Combination of different tests will help to establish alcohol as underlying reason and to assess the stage of liver disease. ALD: Alcoholic liver disease; HCC: Hepatocellular carcinoma; CDT: Carbohydrate deficient transferrin; MCV: Mean corpuscular volume; CT: Computed tomography; MRI: Magnetic resonance imaging; TE: Transient elastography; ARFI: Acoustic radiation force impulse imaging elastography (Siemens); CAP: Controlled attenuation parameter (Echosens); MRE: Magnetic resonance elastography; SWE: Shear wave elastography (Supersonic imaging); GGT: γ-glutamyl transpeptadase; GOT: Glutamic-oxal(o)acetic transaminase; GPT: Glutamate pyruvate transaminase; AFP: α-fetoprotein.
CLINICAL APPROACH TO ALD
The diagnosis of ALD has first to establish the consumption of alcohol as cause of the liver disease. Beside serum alcohol concentration measurements as indicator for alcohol consumption within the last 20 h, no serologic marker can be used to monitor chronic alcohol consumption on its own. Ethyl glucuronide levels in the urine (up to 3 d) and, more widely, carbohydrate deficient transferrin (CDT) are being used to detect alcohol consumed previously (4 -21 d). CDT is only a reliable marker if more than 50 g alcohol are consumed per day and even then shows a moderate sensitivity of 60%. A rather new and longer tracking of alcohol consumption is provided by determination of ethyl glucuronide in the hair, which is especially useful in the transplant setting. Next, the pathologic stages of ALD should be ascertained such as steatosis, steatohepatitis, fibrosis/cirrhosis (Figure 2). Sometimes, the diagnosis of ALD is not so obvious because alcohol consequences may manifest for example in the brain (Wernicke Korsakov Syndrome), in the peripheral nerves (polyneuropathy) or as alcoholic cardiomyopathy. Therefore, they may need a more extended clinical view on the patient symptoms from experienced physicians. Along with rib fractures commonly seen on X ray images, other clinical symptoms such as parotid enlargement, Dupuytren’s contracture, and clinical findings are highly associated with ALD.
HISTOLOGY AND ALD
Liver biopsy is still considered the gold standard for assessment of fibrosis/cirrhosis particular in the context of ALD. This is especially the case when in doubt or when non-invasive tests are unreliable. Liver biopsy can be done percutaneous, transjugular or laparoscopic with the latter having probably the safest risk profile. In ALD patients with severe steatohepatitis or AH, which require certain medication, e.g., corticosteroids and/or pentoxifylline or in patients with suspected comorbidities such as HCV or NASH, biopsies are highly indicated. Furthermore, liver biopsy may be necessary to establish the nature of hepatic lesions.
In the daily clinical routine, however, liver biopsy is often limited in ALD patients due to technical requirements (cylinder size larger than 15 mm), inter-observer variability and sampling errors with regard to fibrosis staging which can reach 30%[18-22] or mild (pain and small bleedings in 6%) or severe complications (fatal perforations and bleedings in 0.1%)[23,24]. Because of newly introduced elastographic techniques, liver biopsy should no longer be regularly performed to quantitate fibrosis stage or steatosis except in complex cases or studies. Elementary histological features in ALD include steatosis, with macro- and micro-vesicles, hepatocellular ballooning, inflammatory infiltrates (neutrophils) that predominate in the lobules and variable degrees of fibrosis including pericellular fibrosis and lobular distortion perhaps progressing to cirrhosis.
Patients symptoms may range from a single lesion or combinations of elementary lesions[26,27]. Until today, the prevalence and distribution of histological lesions among heavy drinkers is not well known. Naveau et al showed in a large study of 1604 patients diagnosed with ALD undergoing liver biopsy that 14% of patients had normal liver, 28% steatosis without fibrosis, 20% presented with fibrosis (with or without steatosis), 8.5% with acute AH, and 29% indicated cirrhosis. Table 2 shows number and percentage of fibrosis stages of the Heidelberg cohort of patients undergoing alcohol detoxification. In the biopsy-proven group (n = 89), ca. 30% were F3-4 while almost no one was F0. In patients staged by transient elastography after alcohol withdrawal (n = 275) 60.7% were classified as F0 and 41.8% were F3-4. These data indicate that biopsy-proven studies are naturally biased missing many patients without liver cirrhosis. Table 3 shows the distribution of histological features in the biopsy proven cohort. More than 70% showed steatosis and 75.3% steatohepatitis.
Table 2 Fibrosis stages of alcoholic liver disease patients undergoing alcohol detoxication as determined by liver biopsy n (%).
Preliminary data from Salem Medical Center (n = 364). TE: Transient elastography.
Table 3 Relative distribution of histological features in alcoholic liver disease patients.
Kleiner score (range)
Kleiner steatosis 0-3
Lobular inflammation 0-3
Portal inflammation 0-1
Mallory hyaline 0-1
Classification steatohepatitis 0-2
Preliminary data from Salem Medical Center (n = 89).
Steatosis represents the early phase of ALD and is most frequently seen in injured livers. Nevertheless, it is still not clear whether simple steatosis is a benign condition, a prerequisite for further progression towards steatohepatitis or even a compensatory protective reaction. Alcoholic steatohepatitis (ASH) is characterized by steatosis in combination with hepatocyte ballooning, hepatocellular damage and tissue inflammation represented by infiltrates of polymorphonuclear cells. Among ASH, steatosis and the extent of fibrosis, ASH demonstrated the highest risk for cirrhosis development in at least 40% of cases[30-35]. The assessment of the fibrosis degree should be performed by special techniques, such as trichrome or Sirius red staining. Reticulin is commonly used to assess the extent of fibrosis and liver architecture in parallel. Despite missing validation in the setting of ALD, semi-quantitative methods such as the Metavir scale are also used. The Kleiner-Brunt score, originally developed for NAFLD, has been recently used in ALD studies since NAFLD and ALD show common features if not to the same extent[36,37].
NON-INVASIVE DIAGNOSIS OF ALCOHOLIC STEATOSIS
Early screening for steatosis can be carried out using ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). Among those methods, hepatic steatosis assessment via US, especially in patients below 30% fat deposition has poor analytical sensitivity and specificity. MRI and MR technique are the imaging tools of choice allowing for accurate steatosis assessment but limited by the lack of established standardization of sequence characteristics and their high cost[39,40]. Recent ultrasound based techniques such as CAP are promising. CAP is run on the Fibroscan platform and so far restricted to the M probe. CAP is reproducible and quantitative with an AUROC up to 90% for fatty liver. However, the histological validation of alcoholic steatosis and CAP in large studies with ALD patients is still pending. More details are given below. In clinical practice, US can be proposed in heavy drinkers as a screening procedure for steatosis.
NON-INVASIVE DIAGNOSIS OF ALD BY BLOOD TESTS
ALD patients are represented by characteristic laboratory findings depending on the stage of liver disease. One of the best marker in ALD is elevated γ-glutamyl transpeptadase (GGT) representing an induction of enzymatic activity with a combined sensitivity and specificity of > 70%[43,44]. In addition, GGT activity is not very specific for alcohol intoxication and can be also caused by other conditions namely cholestastic liver disease, cardiac insufficiency, drugs and many more. Furthermore, serum GGT looses its alcohol specificity in more advanced stages[12,45]. Glutamic-oxal(o)acetic transaminase (GOT) is typically elevated in severe AH while GOT levels > 300 U/L are rarely detected. In about 70% of patients with non-viral liver disorders, the GOT/glutamate pyruvate transaminase (GPT) ratio is higher than two. In cirrhotic stages, transaminases may normalize and GOT levels are slightly continuously increased in the absence of alcohol consumption. The blood test also shows alterations in patients with ALD, such as an increased mean cell volume (MCV) being equally sensitive as elevated transaminases, low numbers of platelets as indicator for cirrhosis or elevated leukocytes as marker for acute alcoholic steatohepatitis. The combination of GGT, MCV, IgA, CDT, and GOT/GPT ratio increases the diagnostic accuracy for ALD with a sensitivity and specificity > 90%. Elevated direct bilirubin levels are also increasingly noted in ALD patients either due to cirrhosis or severe steatohepatitis. Table 4 illustrates typical routine blood tests together with some common ultrasound parameters in patients with ALD from our Heidelberg cohort (n = 364). The fibrosis profile of this population for F0, F1-2, F3 and F4 cirrhosis is 61.7%, 10%, 10% and 18.1%. Changes in iron metabolisms and iron related proteins may be also detected and can be easily mixed up with e.g., hereditary hemochromatosis. In the Heidelberg population, serum ferritin levels are above normal (> 400 ng/mL) in 37% and higher than 1000 ng/mL in 16% (see also Table 4). Transferrin saturation is also often elevated (> 45%) in 36% and > 60% in more than ca. 20% of patients which indicates that transferrin saturation is not indicative for hereditary iron overload (see also Table 4). Therefore, alcohol withdrawal for at least four weeks is recommended since liver iron parameters will change slowly.
Table 4 Typical routine blood tests in alcoholic liver disease.
Bilirubin total (mg/dL)
Hepatic steatosis (US)
Spleen size (cm)
Signs of cirrhosis (US)
Liver stiffness (final)
The table shows percentage and means of pathologic routine blood tests in patients with alcoholic liver disease (ALD) (preliminary data from Salem Medical Center n = 275) solely characterized by non-invasive transient elastography (TE). US: Ultrasonography; CAP: Controlled attenuation parameter (Echosens); GGT: γ-glutamyl transpeptadase; GOT: Glutamic-oxal(o)acetic transaminase; GPT: Glutamate pyruvate transaminase; AFP: α-fetoprotein; AP: Alkaline phosphatase.
NON-INVASIVE DIAGNOSIS OF ALCOHOLIC LIVER FIBROSIS/CIRRHOSIS
Hepatic imaging techniques
US, MRI and CT may allow the assessment of steatosis or more advanced stages, help to exclude other causes of chronic liver disease and its complications independent of the etiology. Imaging techniques could help to exclude other causes of abnormal liver tests, such as obstructive cholestasis, infiltrative or neoplastic liver diseases. With respect to fibrosis assessment, all imaging techniques have to rely on so called sure morphological signs of cirrhosis such as nodular aspects of the liver or recanalization of the umbilical vein while splenomegaly or ascites are not specific. Despite high diagnostic accuracy for the detection of ALD under study conditions, imaging techniques are especially limited in the daily routine in diagnosing compensated liver cirrhosis (sensitivity < 70%) (see also Table 3). Conventional grey scale US is one imaging modality in screening for liver cirrhosis and relies on liver parenchyma abnormalities and morphological changes. Colour Doppler US provides further information on haemodynamics of portal venous system, the hepatic artery and the hepatic veins, but the reliability and reproducibility are limitations for its daily usage as screening tool. US findings can be considered to confirm cirrhotic livers but a negative result cannot fully rule out cirrhosis. Although acoustic structure quantification is a promising new ultrasound software program which provides encouraging results in the diagnosis of cirrhosis/fibrosis, it has to date not attained the same diagnostic performance as Fibroscan. The diagnostic accuracies for cirrhosis detection using MRI and CT were reported with 70% and 67% with sensitivities and specificities of 87%, 84%, 52% and 54%, respectively.
In the last decades, serum markers have been intensively studied to assess fibrosis and inflammation. Table 5 shows important serum fibrosis markers and their outcome in ALD studies. So-called indirect markers correlate with the hepatic function, but not directly with the deposition of extracellular matrix. Indirect markers are e.g., platelet count, parameter of liver synthesis, such as INR or albumin and transaminase levels. In contrast, direct markers are tightly associated with matrix deposition, the key feature of liver cirrhosis. Examples of such markers are hyaluronic acid, procollagen Type I and III and TIMP1. Some more complex systems combine direct and indirect markers (see Table 5).
Table 5 Serum fibrosis markers in alcoholic liver disease.
Correlation of PIIINP with fibrosis, but not inflammation or steatosis; PIIINP also positively correlated with ALP and GGT
TH-IV concentration as best marker to distinguish ALD from non-ALD; good correlation between hepatic type V collagen and serum TH-IV, but not 7S-IV collagen; TIMP, may be useful in evaluating the degree of hepatic fibrosis
Four fibrosis serum marker systems have been extensively studied: FibroTest/FibroSure, Hepascore, FibroSpect and the ELF test (“European Liver Fibrosis Study Group panel”). The ideal serum marker should be specific, non-invasive, reproducible, be correlated with disease severity and prognosis and unaffected by drugs and other (metabolic) conditions. Today available markers do not meet all of these requirements because they are not liver-specific, may represent impaired hepatic clearance or are affected by inflammation rather than fibrosis stage. Some liver disease specific markers e.g., the APRI score is widely used in viral hepatitis but useless in ALD.
In principle, serum markers allow a good differentiation between F0-1 and F2-4 and no special equipment is required. For some patented tests (e.g., Fibrotest), however, serum needs to be sent to special institutions and the real algorithm (exclusion criteria) cannot be validated. Fibrotest has been evaluated in ALD and has reached a diagnostic accuracy of 0.8. Other markers include the ELF test or determination of cytokeratin 18 (CK18). Unfortunately, the possible interference of these markers with steatohepatitis has not been studied and they were not applied in clinical practice. Interestingly, the best single serum marker was hyaluronic acid formerly introduced by Parés et al showing a significant correlation with the histological fibrosis independent of the inflammatory status. Future studies are required to better define which serum markers should be used in cases where no liver stiffness (LS) can be obtained and to which extent it is modified by co-existing inflammation.
Fibrotest®, a marker panel analysing alpha-2-macroglobulin, haptoglobin, GGT, ApoA1 and bilirubin and corrected for age and sex has high diagnostic potential for the detection of significant fibrosis in patients with ALD. In a study of 221 patients with biopsy-proven ALD, the mean Fibrotest® value ranged from 0.29 in patients with F0 to 0.88 in those with F4 cirrhosis. For the diagnosis of F4 cirrhosis, the AUROC was very high (0.95). FibrometerA®, combining PT, alpha-2-macroglobulin, hyaluronic acid and age has similar diagnostic accuracy in ALD with an AUROC of 0.962. The diagnostic value of Hepascore® combining bilirubin, GGT, hyaluronic acid, alpha-2-macroglobulin, age and sex did not differ from that of FibrometerA® or Fibrotest® and was significantly greater than those of non-patented biomarkers (APRI, Forns, FIB4). The combination of any of these tests did not improve diagnostic accuracy. In addition to their diagnostic performance in the screening of fibrosis, non-invasive tests may be useful in predicting liver-related mortality as shown in a study of patients with ALD followed-up for more than 8 years, where survival was correlated with baseline non-invasive fibrosis score. The so-called ELF® test may also predict clinical outcomes in patients with chronic liver disease but its efficacy needs further evaluation in larger ALD cohorts. Preliminary comparative analysis from the Heidelberg Center suggests that the formerly introduced single hyaluronic acid is quite useful and could well serve as backup marker in those ALD patients that cannot be measured by elastography.
Assessment of fibrosis stage by elastographic techniques via LS
The new approaches to assess LS have significantly improved the diagnosis of liver fibrosis[60,61]. TE (Fibroscan®) was the first technique to be introduced. Consequently, most published LS studies have been performed with TE. In the last year, Fibroscan was also approved by the FDA in the United States. Acoustic radiation force impulse imaging (ARFI, Siemens) and shear wave elastography (SWE, Supersonic Imaging) are additional competing ultrasound-based techniques that are commercially available. Magnetic resonance elastography (MRE) hold great promises for three-dimensional assessment of stiffness in various organs not restricted to the liver. However, it is routinely used only in few centers. First comparative studies indicate that ARFI, SWE and MRE are matching with TE with regard to accuracy. Future studies will identify individual limitations and strengths. We here consider the interpretation of LS in general and independent of the methodology. Unfortunately, different non-standardized units are used by the above mentioned techniques that may lead to confusion when comparing different studies.
LS is an excellent surrogate marker of advanced fibrosis (F3) and cirrhosis (F4) in ALD and superior to all serum markers. LS scale with cut-off values for various fibrosis stages in ALD are shown in Figure 3. LS values below 6 kPa are generally considered as normal and exclude even mild fibrosis (Figure 3). Although severe fat deposition may lower LS, it rarely has an impact on fibrosis stage determined by LS. Due to the narrow “gray range” from 6 to 8 kPa and potential interferences (positioning, breathing or eating), an exact discrimination between F1 and F2 stages is not recommended for clinical purpose. Finally, LS highly correlates with portal pressure and esophageal varices and HCC are likely at LS > 20 kPa[60,61]. However, LS can be also elevated by inflammation[63,64], liver congestion, and mechanic cholestasis in the absence of fibrosis. Since all these conditions may be present in ALD patients, LS should always be interpreted in the context of imaging, laboratory and clinical findings. Table 6 lists all biopsy-proven studies on patients with ALD so far. Although an excellent performance could be shown in all studies, they differ quite drastically with regard to the cut-off values. In our opinion, this is mainly due to the presence of inflammation as assessed by transaminase levels. In this study, we demonstrated that LS decreases in patients with ALD during alcohol withdrawal. The decrease of LS was best estimated based on GOT levels. Thus, GOT levels higher than 100 U/L were predictive for an inflammation-associated elevation of LS. When only considering patients with low or normal transaminase levels, cut-off values were comparable to those observed in patients with viral hepatitis, e.g., 12.5 kPa for F4 cirrhosis. In addition, the diagnostic accuracy of LS could be improved when considering the GOT levels. These data have also been confirmed by others. In our present cohort of 364 patients undergoing alcohol withdrawal, the overall mean decrease of LS was 10%, which transformed into overestimation of fibrosis stage in 27%. In some patients, fibrosis stage changed up to three degrees after alcohol withdrawal. For these reasons, we require actual laboratory testing for correct LS interpretation. More practical algorithms are provided below.
Figure 3 Liver stiffness scale with cut-off values for various fibrosis stages in alcoholic liver disease patients without pronounced inflammation, congestion, tumors or mechanic cholestasis.
Table 6 Liver stiffness and fibrosis stages in alcoholic liver disease (biopsy proven studies).
In Figure 4, the work up plan is shown as applied daily at the Salem Medical Center. After suspicion of ALD either by patients reporting, clinical or laboratory signs, TE is performed directly after the abdominal ultrasound and routine blood tests. During the ultrasound, liver size, spleen size, morphology, abnormalities such as congestion, cholestasis, morphological signs of cirrhosis, the presence of ascites and the diameter of the lower caval vein are assessed. TE is then performed either with the M probe or in cases of M probe failure, obvious obesity or ascites with the XL probe[68,69]. If LS was elevated and patients had GOT > 100 U/mL, alcohol withdrawal for at least 2 wk is recommended followed by a second LS measurement. The following practical setting is applied in Heidelberg: (1) we always perform the LS measurement right after the abdominal ultrasound. By doing so, direct and indirect ultrasound criteria for cirrhosis are seen and important other non-cirrhotic factors for an increased LS (congestion, cholestasis, tumors, others) are diagnosed; (2) a LS < 6 kPa excludes cirrhosis and even mild fibrosis; (3) if the LS > 12.5 kPa, the patient has compensated cirrhosis in case of GOT levels < 100 U/L. Transaminases typically normalize within 1-3 wk, so LS can always be re-measured after 1-3 wk of abstaining from alcohol; and (4) in patients with LS > 30 kPa, the diagnosis of cirrhosis is settled despite steatohepatitis as measured by elevated transaminase levels. At these levels, the development of ascites is very likely.
Figure 4 Complete non-invasive diagnostic work plan for patients with alcoholic liver disease at Salem Medical Center Heidelberg with follow up.
Flow scheme allowed diagnosis of fibrosis in 95% of patients. In the remaining 5% of patients without valid LS measurements, the role of serum markers need to be settled but single hyaluronic acid looks promising. In patients with LS > 30 kPa, cirrhosis is established despite increased transaminase levels. MCV: Mean corpuscular volume; HCC: Hepatocellular carcinoma; LS: Liver stiffness; US: Ultrasonography; GGT: γ-glutamyl transpeptadase; GOT: Glutamic-oxal(o)acetic transaminase; GPT: Glutamate pyruvate transaminase; AFP: α-fetoprotein.
This approach allows definitive non-invasive assessment of fibrosis stage in ca. 95%. Compared to conventional routine ultrasound, TE identifies twice as many patients with advanced fibrosis/cirrhosis and has a smaller sample error as compared to histology (3%-5% vs 20%-50%). In a recent French elastography screening study on more than 1000 apparently healthy people older than 45 years, 7.5% had a pathologically increased liver stiffness > 8 kPa with 36% of them eventually being due to ALD. Therefore, it is anticipated that these novel non-invasive screening tools will improve the early recognition and follow up of patients with ALD, the most common and unfortunately too often underestimated liver disease. Whether in addition GOT-adapted cut-off values should be used e.g., for ad hoc decisions in patients with no time or options to withdraw from alcohol, remains still a matter of debate.
Importance to discriminate between impaired liver synthesis and portal hypertension in cirrhotic patients
One problem in discussing the term liver cirrhosis is the fact that histomorphological features of liver cirrhosis (gold standard) are associated with a broad variety of clinical symptoms and complications. Dependent on their clinical specialization, physicians will be confronted with different aspects of the liver disease and, consequently, will have a distinct look on liver cirrhosis per se. This sometimes causes a different usage of terminology. Figure 5 demonstrates that liver cirrhosis manifests in every patient individually via clinically different but diagnostically accessible routes mainly due to impaired synthesis, metabolic activity and detoxification or portal hypertension. Although both impairments, portal hypertension or reduced synthesis, can coexist in every patient and are highly associated with each other, patients exist in which one or the other impairment is dominant and determines prognosis and survival.
Figure 5 Clinical significance of synthesis impairment and portal hypertension in cirrhotics.
Both factors are independently and individually occurring in cirrhotic patients and determine the individual risk of severe complications (framed). While synthesis is easily assessed by lab tests, elastographic techniques are the future highly sensitive method of choice to identify patients with portal hypertension. HCC: Hepatocellular carcinoma; SBP: Systolic blood pressure.
Thus, the degree of synthesis impairment and portal hypertension should be evaluated separately to better determine the natural course and potential complications. In practice, patients can be seen with normal synthesis parameters but pronounced portal hypertension and vice versa. Despite normal INR and albumin levels, they can develop massive ascites and may later die from spontaneous bacterial peritonitis or varical bleeding. Such patients have a stiff liver and show vast matrix deposition in the biopsy. In contrast, other patients show rather early signs of icterus and impaired coagulation tests but portal hypertension is less pronounced. More research needs to be performed to better understand genetic determinants of these individual natural courses. The different aspects of liver cirrhosis and the absence of standardized usage of terminology are challenged by novel elastographic methods. It can be expected that liver cirrhosis will be evaluated differently in the near future. The new perspective may easily explain why conventional laboratory based scores rather detect the synthesis-impaired cirrhotics but overlook patients with portal hypertension. By contrast, we think that elastographic techniques are highly sensitive to identify patients with portal hypertension as also suggested in a recent Korean study by Hong et al.
AH is characterized by a high mortality rate and typically affects younger patients with a shorter drinking history. Despite much effort, invasive and non-invasive methods for early AH detection are limited and diagnosis by serum markers or histology is still a matter of controversies. So far, liver transplantation is the therapy of choice with a success rate of 90%[73,74]. However, it is not allowed in most countries before 6 mo of abstinence. In addition, only a small group of patients with early bilirubin response and no contraindications are candidates for steroids or pentoxifylline. At the moment, there is a huge controversy of using non-invasive clinical vs histological scores the latter being recommended by most guidelines. Table 7 shows three more recently introduced histological scores to assess alcoholic hepatitis with an AUROC of ca. 0.8 to predict 90-d survival. Moreover, biliary features seem to be of high interest to early recognize signs of infection, sepsis and poor prognosis.
Table 7 Histological scores for alcoholic hepatitis.
It is interesting to note, that the well-established clinical scores (Table 8) show a comparable AUROC to predict survival. As shown in Table 8, major non-invasive routine markers that have been identified in various studies include INR, bilirubin, creatinine, age, leukocytes, urea, albumin and decrease of bilirubin over 7 d. Unfortunately, both clinical and histological scores are not yet accurate enough and none of the studies really compared all clinical scores vs all histological scores. Preliminary first observations also suggest that liver stiffness will not add any new and helpful information with regard to prognosis of AH. Interestingly, transaminase levels are usually only slightly increased and are also not predictive. Recent data suggest that serum CK18 fragments (M65 and M30) are highly sensitive and more significant markers of the histological degree of inflammation and liver damage clearly exceeding transaminase levels. In addition, a recent study on ALD patients undergoing alcohol detoxification showed an unexpected increase of M30 while M65 and transaminases decreased or even normalized. These data could give a first hint on the role of dysregulated apoptotic events during AH.
Various aspects of ALD could be potentially assessed in a non-invasive manner and a broad and diverse array of promising techniques are currently under investigation. This paragraph is far from being complete and only a few novel methods are mentioned for the lack of space.
With regard to hepatic steatosis, CAP (controlled attenuation parameter) looks very encouraging and is already commercially available. CAP uses a sophisticated process based on vibration control transient elastography (VCTE, Fibroscan) but is so far restricted to the M probe. CAP was first validated as an estimate of ultrasonic attenuation at 3.5 MHz using Field II simulations and tissue-mimicking phantoms. Although ALD was not addressed specifically, CAP correlated well with the histological degree of steatosis (Spearman rho = 0.81, P < 10-16) and the AUROC was equal to 0.91 and 0.95 for the detection of more than 10% and 33% of steatosis, respectively. Factors significantly associated with elevated CAP were BMI (> 30 kg/m2), metabolic syndrome, alcohol consumption of higher than 14 drinks per week and an elevated liver stiffness. Comparative studies in patients with NAFLD, HCV and HBV indicated that CAP seems to work independent of the etiology of the liver disease and ethnic origin.
ALD patients often show pathological high iron deposits in the liver. Iron could lead to progressive liver disease because of its high cancerogenicity due to Fenton-like reactions thereby determining outcome. Both the underlying mechanisms and potential therapeutic approaches are still unresolved. In addition, it is often overlooked that routine iron parameters do not reliably reflect hepatic iron overload namely in patients with ALD. Techniques such as the SQUID technology are only on few places worldwide available and are too expensive for screening purposes. Although modified MRI techniques can principally be used to quantitate hepatic iron and are used in some centers to measure liver iron in e.g., patients with heavy iron overload such as β-thalassemia, they have not been really explored in ALD patients. Furthermore, their potential interferences and detection limits in such common metabolic liver diseases have not been carefully studied. The recently developed room temperature susceptometer[80,81] seems to be an alternative approach and first preliminary data on ALD patients at Salem Medical Center are encouraging.
It is surprising that information from the exhaled air have not been more intensively explored given the enormous technical progress e.g., such as mass spectroscopy. A few studies have been published so far. Millonig et al tested if ion-molecule-reaction mass spectrometry combined with a new statistical modality could be used for the diagnosis of liver diseases including some individuals with alcoholic fatty liver disease. Characteristic exhalation patterns could be identified reaching an AUROC for individual liver diseases between 0.88 and 0.97. Other authors tested whether volatile compounds from breath samples as detected by selected-ion flow-tube mass spectrometry correlate with the diagnosis of AH and the severity of liver disease in patients with AH. In this study six compounds (2-propanol, acetaldehyde, acetone, ethanol, pentane and trimethylamine) were identified whose levels were increased in patients with liver disease compared with control subjects.
Quantification of hepatocyte cell death by circulating CK18 levels and its caspase-cleaved fragments has been recently explored to evaluate the progression of ALD. M30 and M65 antibodies can be used for monitoring liver cell death in heavy alcoholics[85,86]. CK18 was higher in the serum of heavy drinkers as compared to controls and also increased in patients with alcoholic hepatitis when compared to patients with fatty liver. Furthermore urinary levels of full length CK18 are enhanced in alcoholics. Recently, Lavallard et al quantified and correlated CK18 and its fragments in the serum of 143 heavy alcoholics with disease severity. They reported a strong correlation of CK18 and its fragments with Mallory-Denk bodies, ballooning, fibrosis and with hepatic TNF-α and TGF-β assessed in the liver of 24 patients. Elevated levels of serum hepatocyte death and apoptotic markers were independent risk factors in predicting severe fibrosis in a model combining alkaline phosphatase, bilirubin, prothrombin index, HA, hepatocyte death and apoptotic markers (AUROC 0.84 and 0.76). Recent data suggest that M65 and M30 are highly sensitive and more significant markers of the histological degree of inflammation and liver damage clearly exceeding transaminase levels. In addition, a recent study on ALD patients undergoing alcohol detoxification showed an unexpected increase of M30 while M65 and transaminases decreased or even normalized. These data could give a first hint on the role of dysregulated apoptotic events during AH. Another study examined the tumor necrosis factor related apoptosis inducing ligand (TRAIL) as essential factor involved in apoptosis in liver injury animal models after alcohol consumption. They showed that after alcohol consumption in the livers of animals virally transfected with TRAIL, TRAIL expression led to hepatic steatosis, without hepatocyte cell death, indicating that TRAIL-mediated apoptosis and steatosis may be independently modulated after viral infection and alcohol intake. Therefore, TRAIL was proposed as a new mediator of hepatic steatosis after alcohol intake. An additional approach could be the analysis of Stat3 DNA-binding in ALD patients, because in vitro and animal studies suggest that alcohol might interfere with Stat3 signaling, a regulator of hepatocyte cell death and proliferation[90-92]. Stärkel et al assessed Stat3 expression, binding activity and the apoptotic-proliferation balance in ALD patients and found no detectable Stat3 DNA-binding activity in all ALD samples. This was also associated with high Pias3 expression, but not with increased Socs3 levels. Bcl-2 was upregulated in ALD together with decreased Caspase-3 activity. They concluded from the results that alcoholic cirrhosis is characterized by impaired Stat3 DNA-binding activity and this might contribute to disturbed liver regeneration and repair and the fatal outcome.
Genetic profiling (PNPLA3)
Since only 15% of heavy drinkers will develop cirrhosis, it has been conceived for a long time that genetic factors are important disease modifiers in ALD. Studies examining ethnic factors, familial history or twin studies point also to ALD as a genetically determined disease[95,96]. Only recently, a genome-wide association study (GWAS) identified a small nucleotide polymorphism (SNP; rs738409 C->G) in the patatin-like phospholipase domain containing 3 (PNPLA3/Adiponutrin) gene as genetic variant associated with steatosis. Several studies confirmed that this variant predisposes towards all stages of liver damage starting from simple steatosis to steatohepatitis and progressive fibrosis and is also linked to increased risk of ALD (steatohepatitis to cirrhosis)[98,99]. In a well-characterized cohort of ALD patients, a significant correlation was found between the GG allelic variant with histological signs of hepatocyte damage (microgranulomas and ballooning r > 0.3, P < 0.005) but less with histological steatosis (r = 0.24, P < 0.05). Therefore, the determination of SNP status and following consequences will reveal novel mechanisms involved in ALD development and progression and may possibly help to establish new treatment options.
Further intensively discussed markers of diagnostic potential include miRNA[101-103] and osteopontin[104,105] just to name a few. It is quite conceivable that the intensive search for novel physical or molecular markers will drastically improve the non-invasive management of ALD in the upcoming decade.
P- Reviewer: Ahn SH, Colecchia A, Kim SU S- Editor: Ma YJ L- Editor: A E- Editor: Wang CH
McCullough AJ, O’Connor JF. Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology.Am J Gastroenterol. 1998;93:2022-2036.
Kim KA. Current status of liver diseases in Korea: toxic and alcoholic liver diseases.Korean J Hepatol. 2009;15 Suppl 6:S29-S33.
Maher JJ. Alcoholic liver disease.Gastrointestinal and Liver Disease Vol II. Philadelphia: Saunders 2002; 1375-1391.
Cortez-Pinto H, Gouveia M, dos Santos Pinheiro L, Costa J, Borges M, Vaz Carneiro A. The burden of disease and the cost of illness attributable to alcohol drinking--results of a national study.Alcohol Clin Exp Res. 2010;34:1442-1449.
Cochrane J, Chen H, Conigrave KM, Hao W. Alcohol use in China.Alcohol Alcohol. 2003;38:537-542.
Park SH, Kim CH, Kim DJ, Park JH, Kim TO, Yang SY, Moon YS, Kim TN, Kim HK, Park HY. Prevalence of alcoholic liver disease among Korean adults: results from the fourth Korea National Health and Nutrition Examination Survey, 2009.Subst Use Misuse. 2011;46:1755-1762.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012;380:2095-2128.
Mueller S. Pharmacological blockage of CYP2E1 and alcohol-mediated liver cancer: is the time ready?Chin J Cancer Res. 2013;25:269-271.
Seitz HK, Mueller S. Alcoholic liver disease.Clinical Hepatology: Principles and Practice of Hepatobiliary Diseases. Heidelberg, Dordrecht, Londong, New York: Springer 2009; 1111-1152.
European Association for the Study of Liver. EASL clinical practical guidelines: management of alcoholic liver disease.J Hepatol. 2012;57:399-420.
Stickel F, Seitz HK. Update on the management of alcoholic steatohepatitis.J Gastrointestin Liver Dis. 2013;22:189-197.
Maddrey WC, Boitnott JK, Bedine MS, Weber FL, Mezey E, White RI. Corticosteroid therapy of alcoholic hepatitis.Gastroenterology. 1978;75:193-199.
Forrest EH, Evans CD, Stewart S, Phillips M, Oo YH, McAvoy NC, Fisher NC, Singhal S, Brind A, Haydon G. Analysis of factors predictive of mortality in alcoholic hepatitis and derivation and validation of the Glasgow alcoholic hepatitis score.Gut. 2005;54:1174-1179.
Louvet A, Naveau S, Abdelnour M, Ramond MJ, Diaz E, Fartoux L, Dharancy S, Texier F, Hollebecque A, Serfaty L. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids.Hepatology. 2007;45:1348-1354.
Agius R, Nadulski T, Kahl HG, Dufaux B. Ethyl glucuronide in hair - A highly effective test for the monitoring of alcohol consumption.Forensic Sci Int. 2012;218:10-14.
Abdi W, Millan JC, Mezey E. Sampling variability on percutaneous liver biopsy.Arch Intern Med. 1979;139:667-669.
Bedossa P, Dargère D, Paradis V. Sampling variability of liver fibrosis in chronic hepatitis C.Hepatology. 2003;38:1449-1457.
Cadranel JF, Rufat P, Degos F. Practices of liver biopsy in France: results of a prospective nationwide survey. For the Group of Epidemiology of the French Association for the Study of the Liver (AFEF).Hepatology. 2000;32:477-481.
Maharaj B, Maharaj RJ, Leary WP, Cooppan RM, Naran AD, Pirie D, Pudifin DJ. Sampling variability and its influence on the diagnostic yield of percutaneous needle biopsy of the liver.Lancet. 1986;1:523-525.
Regev A, Berho M, Jeffers LJ, Milikowski C, Molina EG, Pyrsopoulos NT, Feng ZZ, Reddy KR, Schiff ER. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection.Am J Gastroenterol. 2002;97:2614-2618.
Gilmore IT, Burroughs A, Murray-Lyon IM, Williams R, Jenkins D, Hopkins A. Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London.Gut. 1995;36:437-441.
McGill DB, Rakela J, Zinsmeister AR, Ott BJ. A 21-year experience with major hemorrhage after percutaneous liver biopsy.Gastroenterology. 1990;99:1396-1400.
Hall PD. Pathological spectrum of alcoholic liver disease.Alcohol Alcohol Suppl. 1994;2:303-313.
Naveau S, Giraud V, Borotto E, Aubert A, Capron F, Chaput JC. Excess weight risk factor for alcoholic liver disease.Hepatology. 1997;25:108-111.
Edmondson HA, Peters RL, Frankel HH, Borowsky S. The early stage of liver injury in the alcoholic.Medicine (Baltimore). 1967;46:119-129.
Galambos JT. Natural history of alcoholic hepatitis. 3. Histological changes.Gastroenterology. 1972;63:1026-1035.
Galambos JT, Shapira R. Natural history of alcoholic hepatitis. IV. Glycosaminoglycuronans and collagen in the hepatic connective tissue.J Clin Invest. 1973;52:2952-2962.
Marbet UA, Bianchi L, Meury U, Stalder GA. Long-term histological evaluation of the natural history and prognostic factors of alcoholic liver disease.J Hepatol. 1987;4:364-372.
Parés A, Caballería J, Bruguera M, Torres M, Rodés J. Histological course of alcoholic hepatitis. Influence of abstinence, sex and extent of hepatic damage.J Hepatol. 1986;2:33-42.
Sørensen TI, Orholm M, Bentsen KD, Høybye G, Eghøje K, Christoffersen P. Prospective evaluation of alcohol abuse and alcoholic liver injury in men as predictors of development of cirrhosis.Lancet. 1984;2:241-244.
Mathurin P, Beuzin F, Louvet A, Carrié-Ganne N, Balian A, Trinchet JC, Dalsoglio D, Prevot S, Naveau S. Fibrosis progression occurs in a subgroup of heavy drinkers with typical histological features.Aliment Pharmacol Ther. 2007;25:1047-1054.
Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW, Ferrell LD, Liu YC, Torbenson MS, Unalp-Arida A, Yeh M, McCullough AJ, Sanyal AJ; Nonalcoholic Steatohepatitis Clinical Research N. Design and validation of a histological scoring system for nonalcoholic fatty liver disease.Hepatology. 2005;41:1313-1321.
Mueller S, Millonig G, Sarovska L, Friedrich S, Reimann FM, Pritsch M, Eisele S, Stickel F, Longerich T, Schirmacher P. Increased liver stiffness in alcoholic liver disease: differentiating fibrosis from steatohepatitis.World J Gastroenterol. 2010;16:966-972.
Schwenzer NF, Springer F, Schraml C, Stefan N, Machann J, Schick F. Non-invasive assessment and quantification of liver steatosis by ultrasound, computed tomography and magnetic resonance.J Hepatol. 2009;51:433-445.
d’Assignies G, Ruel M, Khiat A, Lepanto L, Chagnon M, Kauffmann C, Tang A, Gaboury L, Boulanger Y. Noninvasive quantitation of human liver steatosis using magnetic resonance and bioassay methods.Eur Radiol. 2009;19:2033-2040.
Mancini M, Prinster A, Annuzzi G, Liuzzi R, Giacco R, Medagli C, Cremone M, Clemente G, Maurea S, Riccardi G. Sonographic hepatic-renal ratio as indicator of hepatic steatosis: comparison with (1)H magnetic resonance spectroscopy.Metabolism. 2009;58:1724-1730.
Sasso M, Beaugrand M, de Ledinghen V, Douvin C, Marcellin P, Poupon R, Sandrin L, Miette V. Controlled attenuation parameter (CAP): a novel VCTE™ guided ultrasonic attenuation measurement for the evaluation of hepatic steatosis: preliminary study and validation in a cohort of patients with chronic liver disease from various causes.Ultrasound Med Biol. 2010;36:1825-1835.
Ratziu V, Bellentani S, Cortez-Pinto H, Day C, Marchesini G. A position statement on NAFLD/NASH based on the EASL 2009 special conference.J Hepatol. 2010;53:372-384.
Anton RF, Lieber C, Tabakoff B. Carbohydrate-deficient transferrin and gamma-glutamyltransferase for the detection and monitoring of alcohol use: results from a multisite study.Alcohol Clin Exp Res. 2002;26:1215-1222.
Litten RZ, Bradley AM, Moss HB. Alcohol biomarkers in applied settings: recent advances and future research opportunities.Alcohol Clin Exp Res. 2010;34:955-967.
Bell H, Tallaksen C, Sjåheim T, Weberg R, Raknerud N, Orjasaeter H, Try K, Haug E. Serum carbohydrate-deficient transferrin as a marker of alcohol consumption in patients with chronic liver diseases.Alcohol Clin Exp Res. 1993;17:246-252.
Mukai M, Ozasa K, Hayashi K, Kawai K. Various S-GOT/S-GPT ratios in nonviral liver disorders and related physical conditions and life-style.Dig Dis Sci. 2002;47:549-555.
Witters P, Freson K, Verslype C, Peerlinck K, Hoylaerts M, Nevens F, Van Geet C, Cassiman D. Review article: blood platelet number and function in chronic liver disease and cirrhosis.Aliment Pharmacol Ther. 2008;27:1017-1029.
Mueller S. Noninvasive assessment of patients with alcoholic liver disease.Clin Liver Dis. 2013;2:68-71.
Zoli M, Cordiani MR, Marchesini G, Iervese T, Labate AM, Bonazzi C, Bianchi G, Pisi E. Prognostic indicators in compensated cirrhosis.Am J Gastroenterol. 1991;86:1508-1513.
Liu GJ, Lu MD. Diagnosis of liver cirrhosis with contrast-enhanced ultrasound.World J Radiol. 2010;2:32-36.
Ricci P, Marigliano C, Cantisani V, Porfiri A, Marcantonio A, Lodise P, D’Ambrosio U, Labbadia G, Maggini E, Mancuso E. Ultrasound evaluation of liver fibrosis: preliminary experience with acoustic structure quantification (ASQ) software.Radiol Med. 2013;118:995-1010.
Kudo M, Zheng RQ, Kim SR, Okabe Y, Osaki Y, Iijima H, Itani T, Kasugai H, Kanematsu M, Ito K. Diagnostic accuracy of imaging for liver cirrhosis compared to histologically proven liver cirrhosis. A multicenter collaborative study.Intervirology. 2008;51 Suppl 1:17-26.
Lieber CS, Weiss DG, Morgan TR, Paronetto F. Aspartate aminotransferase to platelet ratio index in patients with alcoholic liver fibrosis.Am J Gastroenterol. 2006;101:1500-1508.
Naveau S, Gaudé G, Asnacios A, Agostini H, Abella A, Barri-Ova N, Dauvois B, Prévot S, Ngo Y, Munteanu M. Diagnostic and prognostic values of noninvasive biomarkers of fibrosis in patients with alcoholic liver disease.Hepatology. 2009;49:97-105.
Parés A, Deulofeu R, Giménez A, Caballería L, Bruguera M, Caballería J, Ballesta AM, Rodés J. Serum hyaluronate reflects hepatic fibrogenesis in alcoholic liver disease and is useful as a marker of fibrosis.Hepatology. 1996;24:1399-1403.
Imbert-Bismut F, Ratziu V, Pieroni L, Charlotte F, Benhamou Y, Poynard T. Biochemical markers of liver fibrosis in patients with hepatitis C virus infection: a prospective study.Lancet. 2001;357:1069-1075.
Naveau S, Raynard B, Ratziu V, Abella A, Imbert-Bismut F, Messous D, Beuzen F, Capron F, Thabut D, Munteanu M. Biomarkers for the prediction of liver fibrosis in patients with chronic alcoholic liver disease.Clin Gastroenterol Hepatol. 2005;3:167-174.
Calès P, Oberti F, Michalak S, Hubert-Fouchard I, Rousselet MC, Konaté A, Gallois Y, Ternisien C, Chevailler A, Lunel F. A novel panel of blood markers to assess the degree of liver fibrosis.Hepatology. 2005;42:1373-1381.
Parkes J, Roderick P, Harris S, Day C, Mutimer D, Collier J, Lombard M, Alexander G, Ramage J, Dusheiko G. Enhanced liver fibrosis test can predict clinical outcomes in patients with chronic liver disease.Gut. 2010;59:1245-1251.
Mueller S, Sandrin L. Liver stiffness: a novel parameter for the diagnosis of liver disease.Hepat Med. 2010;2:49-67.
Castera L, Pinzani M. Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango?Gut. 2010;59:861-866.
Nguyen-Khac E, Chatelain D, Tramier B, Decrombecque C, Robert B, Joly JP, Brevet M, Grignon P, Lion S, Le Page L. Assessment of asymptomatic liver fibrosis in alcoholic patients using fibroscan: prospective comparison with seven non-invasive laboratory tests.Aliment Pharmacol Ther. 2008;28:1188-1198.
Sagir A, Erhardt A, Schmitt M, Häussinger D. Transient elastography is unreliable for detection of cirrhosis in patients with acute liver damage.Hepatology. 2008;47:592-595.
Arena U, Vizzutti F, Corti G, Ambu S, Stasi C, Bresci S, Moscarella S, Boddi V, Petrarca A, Laffi G. Acute viral hepatitis increases liver stiffness values measured by transient elastography.Hepatology. 2008;47:380-384.
Millonig G, Friedrich S, Adolf S, Fonouni H, Golriz M, Mehrabi A, Stiefel P, Pöschl G, Büchler MW, Seitz HK. Liver stiffness is directly influenced by central venous pressure.J Hepatol. 2010;52:206-210.
Millonig G, Reimann FM, Friedrich S, Fonouni H, Mehrabi A, Büchler MW, Seitz HK, Mueller S. Extrahepatic cholestasis increases liver stiffness (FibroScan) irrespective of fibrosis.Hepatology. 2008;48:1718-1723.
Trabut JB, Thépot V, Nalpas B, Lavielle B, Cosconea S, Corouge M, Vallet-Pichard A, Fontaine H, Mallet V, Sogni P. Rapid decline of liver stiffness following alcohol withdrawal in heavy drinkers.Alcohol Clin Exp Res. 2012;36:1407-1411.
Kohlhaas A, Durango E, Millonig G, Bastard C, Sandrin L, Golriz M, Mehrabi A, Büchler MW, Seitz HK, Mueller S. Transient elastography with the XL probe rapidly identifies patients with nonhepatic ascites.Hepat Med. 2012;4:11-18.
Durango E, Dietrich C, Seitz HK, Kunz CU, Pomier-Layrargues GT, Duarte-Rojo A, Beaton M, Elkhashab M, Myers RP, Mueller S. Direct comparison of the FibroScan XL and M probes for assessment of liver fibrosis in obese and nonobese patients.Hepat Med. 2013;5:43-52.
Roulot D, Costes JL, Buyck JF, Warzocha U, Gambier N, Czernichow S, Le Clesiau H, Beaugrand M. Transient elastography as a screening tool for liver fibrosis and cirrhosis in a community-based population aged over 45 years.Gut. 2011;60:977-984.
Hong WK, Kim MY, Baik SK, Shin SY, Kim JM, Kang YS, Lim YL, Kim YJ, Cho YZ, Hwang HW. The usefulness of non-invasive liver stiffness measurements in predicting clinically significant portal hypertension in cirrhotic patients: Korean data.Clin Mol Hepatol. 2013;19:370-375.
Casanova J, Bataller R. Alcoholic hepatitis: Prognosis and treatment.Gastroenterol Hepatol. 2014;37:262-268.
Mathurin P, Lucey MR. Management of alcoholic hepatitis.J Hepatol. 2012;56 Suppl 1:S39-S45.
Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V. Early liver transplantation for severe alcoholic hepatitis.N Engl J Med. 2011;365:1790-1800.
Mueller S, Yagmur E, Seitz H, Stickel F, Longerich T, Bantel H. M65 is a highly sensitive marker of alcoholic steatohepatitis.Z Gastroenterol. 2013;51:K127.
de Lédinghen V, Vergniol J, Capdepont M, Chermak F, Hiriart JB, Cassinotto C, Merrouche W, Foucher J, Brigitte le B. Controlled attenuation parameter (CAP) for the diagnosis of steatosis: a prospective study of 5323 examinations.J Hepatol. 2014;60:1026-1031.
Kumar M, Rastogi A, Singh T, Behari C, Gupta E, Garg H, Kumar R, Bhatia V, Sarin SK. Controlled attenuation parameter for non-invasive assessment of hepatic steatosis: does etiology affect performance?J Gastroenterol Hepatol. 2013;28:1194-1201.
Chon YE, Jung KS, Kim SU, Park JY, Park YN, Kim do Y, Ahn SH, Chon CY, Lee HW, Park Y. Controlled attenuation parameter (CAP) for detection of hepatic steatosis in patients with chronic liver diseases: a prospective study of a native Korean population.Liver Int. 2014;34:102-109.
Mueller S, Rausch V. The role of iron in alcohol-mediated hepatocarcinogenesis.Adv Exp Med Biol. 2014;In press.
Maliken BD, Avrin WF, Nelson JE, Mooney J, Kumar S, Kowdley KV. Room-temperature susceptometry predicts biopsy-determined hepatic iron in patients with elevated serum ferritin.Ann Hepatol. 2012;11:77-84.
Avrin WF, Kumar S. Noninvasive liver-iron measurements with a room-temperature susceptometer.Physiol Meas. 2007;28:349-361.
Millonig G, Praun S, Netzer M, Baumgartner C, Dornauer A, Mueller S, Villinger J, Vogel W. Non-invasive diagnosis of liver diseases by breath analysis using an optimized ion-molecule reaction-mass spectrometry approach: a pilot study.Biomarkers. 2010;15:297-306.
Hanouneh IA, Zein NN, Cikach F, Dababneh L, Grove D, Alkhouri N, Lopez R, Dweik RA. The breathprints in patients with liver disease identify novel breath biomarkers in alcoholic hepatitis.Clin Gastroenterol Hepatol. 2014;12:516-523.
Lavallard VJ, Bonnafous S, Patouraux S, Saint-Paul MC, Rousseau D, Anty R, Le Marchand-Brustel Y, Tran A, Gual P. Serum markers of hepatocyte death and apoptosis are non invasive biomarkers of severe fibrosis in patients with alcoholic liver disease.PLoS One. 2011;6:e17599.
Caulín C, Salvesen GS, Oshima RG. Caspase cleavage of keratin 18 and reorganization of intermediate filaments during epithelial cell apoptosis.J Cell Biol. 1997;138:1379-1394.
Ku NO, Liao J, Omary MB. Apoptosis generates stable fragments of human type I keratins.J Biol Chem. 1997;272:33197-33203.
Gonzalez-Quintela A, García J, Campos J, Perez LF, Alende MR, Otero E, Abdulkader I, Tomé S. Serum cytokeratins in alcoholic liver disease: contrasting levels of cytokeratin-18 and cytokeratin-19.Alcohol. 2006;38:45-49.
Barros P, Gonzalez-Quintela A, Mella C, Perez LF. Increased urinary levels of tissue polypeptide specific antigen (TPS) in alcoholics.Anticancer Res. 2006;26:1531-1534.
Mundt B, Wirth T, Zender L, Waltemathe M, Trautwein C, Manns MP, Kühnel F, Kubicka S. Tumour necrosis factor related apoptosis inducing ligand (TRAIL) induces hepatic steatosis in viral hepatitis and after alcohol intake.Gut. 2005;54:1590-1596.
Taub R. Hepatoprotection via the IL-6/Stat3 pathway.J Clin Invest. 2003;112:978-980.
Costa RH, Kalinichenko VV, Holterman AX, Wang X. Transcription factors in liver development, differentiation, and regeneration.Hepatology. 2003;38:1331-1347.
Mangnall D, Bird NC, Majeed AW. The molecular physiology of liver regeneration following partial hepatectomy.Liver Int. 2003;23:124-138.
Stärkel P, De Saeger C, Leclercq I, Strain A, Horsmans Y. Deficient Stat3 DNA-binding is associated with high Pias3 expression and a positive anti-apoptotic balance in human end-stage alcoholic and hepatitis C cirrhosis.J Hepatol. 2005;43:687-695.
Day CP, Bashir R, James OF, Bassendine MF, Crabb DW, Thomasson HR, Li TK, Edenberg HJ. Investigation of the role of polymorphisms at the alcohol and aldehyde dehydrogenase loci in genetic predisposition to alcohol-related end-organ damage.Hepatology. 1991;14:798-801.
Reed T, Page WF, Viken RJ, Christian JC. Genetic predisposition to organ-specific endpoints of alcoholism.Alcohol Clin Exp Res. 1996;20:1528-1533.
Mann RE, Smart RG, Govoni R. The epidemiology of alcoholic liver disease.Alcohol Res Health. 2003;27:209-219.
Romeo S, Kozlitina J, Xing C, Pertsemlidis A, Cox D, Pennacchio LA, Boerwinkle E, Cohen JC, Hobbs HH. Genetic variation in PNPLA3 confers susceptibility to nonalcoholic fatty liver disease.Nat Genet. 2008;40:1461-1465.
Trépo E, Gustot T, Degré D, Lemmers A, Verset L, Demetter P, Ouziel R, Quertinmont E, Vercruysse V, Amininejad L. Common polymorphism in the PNPLA3/adiponutrin gene confers higher risk of cirrhosis and liver damage in alcoholic liver disease.J Hepatol. 2011;55:906-912.
Stickel F, Buch S, Lau K, Meyer zu Schwabedissen H, Berg T, Ridinger M, Rietschel M, Schafmayer C, Braun F, Hinrichsen H. Genetic variation in the PNPLA3 gene is associated with alcoholic liver injury in caucasians.Hepatology. 2011;53:86-95.
Rausch V, Mueller S. Histological hepatocyte damage precedes steatosis in ALD patients with genetic variant I148M in PNPLA3.Z Gastroenterol. 2013;51:K118.
Tang Y, Banan A, Forsyth CB, Fields JZ, Lau CK, Zhang LJ, Keshavarzian A. Effect of alcohol on miR-212 expression in intestinal epithelial cells and its potential role in alcoholic liver disease.Alcohol Clin Exp Res. 2008;32:355-364.
Szabo G, Bala S. Alcoholic liver disease and the gut-liver axis.World J Gastroenterol. 2010;16:1321-1329.
Mandrekar P. Epigenetic regulation in alcoholic liver disease.World J Gastroenterol. 2011;17:2456-2464.
Morales-Ibanez O, Domínguez M, Ki SH, Marcos M, Chaves JF, Nguyen-Khac E, Houchi H, Affò S, Sancho-Bru P, Altamirano J. Human and experimental evidence supporting a role for osteopontin in alcoholic hepatitis.Hepatology. 2013;58:1742-1756.
Altamirano J, Bataller R. Alcoholic liver disease: pathogenesis and new targets for therapy.Nat Rev Gastroenterol Hepatol. 2011;8:491-501.
Gabrielli GB, Faccioli G, Casaril M, Capra F, Bonazzi L, Falezza G, Tomba A, Baracchino F, Corrocher R. Procollagen III peptide and fibronectin in alcohol-related chronic liver disease: correlations with morphological features and biochemical tests.Clin Chim Acta. 1989;179:315-322.
Bedossa P, Poynard T, Abella A, Aubert A, Pignon JP, Naveau S, Leluc R, Lemaigre G, Martin ED, Chaput JC. Apolipoprotein AI is a serum and tissue marker of liver fibrosis in alcoholic patients.Alcohol Clin Exp Res. 1989;13:829-833.
Poynard T, Aubert A, Bedossa P, Abella A, Naveau S, Paraf F, Chaput JC. A simple biological index for detection of alcoholic liver disease in drinkers.Gastroenterology. 1991;100:1397-1402.
Lotterer E, Gressner AM, Kropf J, Grobe E, von Knebel D, Bircher J. Higher levels of serum aminoterminal type III procollagen peptide, and laminin in alcoholic than in nonalcoholic cirrhosis of equal severity.J Hepatol. 1992;14:71-77.
Trinchet JC, Hartmann DJ, Pateron D, Munz-Gotheil C, Callard P, Ville G, Beaugrand M. Serum type I collagen and N-terminal peptide of type III procollagen in patients with alcoholic liver disease: relationship to liver histology.Alcohol Clin Exp Res. 1992;16:342-346.
Li J, Rosman AS, Leo MA, Nagai Y, Lieber CS. Tissue inhibitor of metalloproteinase is increased in the serum of precirrhotic and cirrhotic alcoholic patients and can serve as a marker of fibrosis.Hepatology. 1994;19:1418-1423.
Seitz G, Stickel F, Fiehn W, Werle E, Simanowski UA, Seitz HK. [Carbohydrate-deficient transferrin. A new, highly specific marker for chronic alcohol consumption].Dtsch Med Wochenschr. 1995;120:391-395.
Tsutsumi M, Takase S, Urashima S, Ueshima Y, Kawahara H, Takada A. Serum markers for hepatic fibrosis in alcoholic liver disease: which is the best marker, type III procollagen, type IV collagen, laminin, tissue inhibitor of metalloproteinase, or prolyl hydroxylase?Alcohol Clin Exp Res. 1996;20:1512-1517.
Oberti F, Valsesia E, Pilette C, Rousselet MC, Bedossa P, Aubé C, Gallois Y, Rifflet H, Maïga MY, Penneau-Fontbonne D. Noninvasive diagnosis of hepatic fibrosis or cirrhosis.Gastroenterology. 1997;113:1609-1616.
Johansen JS, Møller S, Price PA, Bendtsen F, Junge J, Garbarsch C, Henriksen JH. Plasma YKL-40: a new potential marker of fibrosis in patients with alcoholic cirrhosis?Scand J Gastroenterol. 1997;32:582-590.
Tran A, Benzaken S, Saint-Paul MC, Guzman-Granier E, Hastier P, Pradier C, Barjoan EM, Demuth N, Longo F, Rampal P. Chondrex (YKL-40), a potential new serum fibrosis marker in patients with alcoholic liver disease.Eur J Gastroenterol Hepatol. 2000;12:989-993.
Tran A, Hastier P, Barjoan EM, Demuth N, Pradier C, Saint-Paul MC, Guzman-Granier E, Chevallier P, Tran C, Longo F. Non invasive prediction of severe fibrosis in patients with alcoholic liver disease.Gastroenterol Clin Biol. 2000;24:626-630.
Plevris JN, Haydon GH, Simpson KJ, Dawkes R, Ludlum CA, Harrison DJ, Hayes PC. Serum hyaluronan--a non-invasive test for diagnosing liver cirrhosis.Eur J Gastroenterol Hepatol. 2000;12:1121-1127.
González-Quintela A, Mella C, Pérez LF, Abdulkader I, Caparrini AM, Lojo S. Increased serum tissue polypeptide specific antigen (TPS) in alcoholics: a possible marker of alcoholic hepatitis.Alcohol Clin Exp Res. 2000;24:1222-1226.
Castera L, Hartmann DJ, Chapel F, Guettier C, Mall F, Lons T, Richardet JP, Grimbert S, Morassi O, Beaugrand M. Serum laminin and type IV collagen are accurate markers of histologically severe alcoholic hepatitis in patients with cirrhosis.J Hepatol. 2000;32:412-418.
Stickel F, Urbaschek R, Schuppan D, Poeschl G, Oesterling C, Conradt C, McCuskey RS, Simanowski UA, Seitz HK. Serum collagen type VI and XIV and hyaluronic acid as early indicators for altered connective tissue turnover in alcoholic liver disease.Dig Dis Sci. 2001;46:2025-2032.
Croquet V, Vuillemin E, Ternisien C, Pilette C, Oberti F, Gallois Y, Trossaert M, Rousselet MC, Chappard D, Calès P. Prothrombin index is an indirect marker of severe liver fibrosis.Eur J Gastroenterol Hepatol. 2002;14:1133-1141.
Nøjgaard C, Johansen JS, Christensen E, Skovgaard LT, Price PA, Becker U. Serum levels of YKL-40 and PIIINP as prognostic markers in patients with alcoholic liver disease.J Hepatol. 2003;39:179-186.
Stickel F, Poeschl G, Schuppan D, Conradt C, Strenge-Hesse A, Fuchs FS, Hofmann WJ, Seitz HK. Serum hyaluronate correlates with histological progression in alcoholic liver disease.Eur J Gastroenterol Hepatol. 2003;15:945-950.
Rosenberg WM, Voelker M, Thiel R, Becka M, Burt A, Schuppan D, Hubscher S, Roskams T, Pinzani M, Arthur MJ. Serum markers detect the presence of liver fibrosis: a cohort study.Gastroenterology. 2004;127:1704-1713.
Nahon P, Kettaneh A, Tengher-Barna I, Ziol M, de Lédinghen V, Douvin C, Marcellin P, Ganne-Carrié N, Trinchet JC, Beaugrand M. Assessment of liver fibrosis using transient elastography in patients with alcoholic liver disease.J Hepatol. 2008;49:1062-1068.
Kim SG, Kim YS, Jung SW, Kim HK, Jang JY, Moon JH, Kim HS, Lee JS, Lee MS, Shim CS. [The usefulness of transient elastography to diagnose cirrhosis in patients with alcoholic liver disease].Korean J Hepatol. 2009;15:42-51.
Janssens F, de Suray N, Piessevaux H, Horsmans Y, de Timary P, Stärkel P. Can transient elastography replace liver histology for determination of advanced fibrosis in alcoholic patients: a real-life study.J Clin Gastroenterol. 2010;44:575-582.
Mookerjee RP, Lackner C, Stauber R, Stadlbauer V, Deheragoda M, Aigelsreiter A, Jalan R. The role of liver biopsy in the diagnosis and prognosis of patients with acute deterioration of alcoholic cirrhosis.J Hepatol. 2011;55:1103-1111.
Affò S, Dominguez M, Lozano JJ, Sancho-Bru P, Rodrigo-Torres D, Morales-Ibanez O, Moreno M, Millán C, Loaeza-del-Castillo A, Altamirano J. Transcriptome analysis identifies TNF superfamily receptors as potential therapeutic targets in alcoholic hepatitis.Gut. 2013;62:452-460.
Dunn W, Jamil LH, Brown LS, Wiesner RH, Kim WR, Menon KV, Malinchoc M, Kamath PS, Shah V. MELD accurately predicts mortality in patients with alcoholic hepatitis.Hepatology. 2005;41:353-358.
Dominguez M, Rincón D, Abraldes JG, Miquel R, Colmenero J, Bellot P, García-Pagán JC, Fernández R, Moreno M, Bañares R. A new scoring system for prognostic stratification of patients with alcoholic hepatitis.Am J Gastroenterol. 2008;103:2747-2756.