MODULE 2A: ALCOHOLIC STEATOSIS

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LEARNING OBJECTIVES

1. Name four enzymes responsible for the metabolism of alcohol and identify two products whose
accumulation lead to derangements in the balance of metabolic pathways in the liver.
2. Compare fatty acid metabolism in the liver under normal conditions and after heavy alcohol
consumption and explain how the latter condition leads to steatosis

Alcoholic Steatosis (AS or fatty liver) is the most common histologic pattern of injury in hepatocytes
exposed to ethanol, representing a classic response to injury in the liver (PSL 539). It develops in nearly
100% of individuals after a bout of heavy drinking and begins within hours of alcohol consumption.

PATHOGENESIS

Key products of ethanol metabolism in the liver are acetaldehyde and NADH

Figure 1 Acetaldehyde is an intermediate in all 3 enzyme systems

Alcohol can be metabolized by three enzyme systems, all of which produce acetaldehyde (Fig. 1).
The main pathway that the liver uses is the alcohol dehydrogenase (ADH) pathway, which produces
NADH as a product. A secondary pathway utilizes the enzyme CYP2E1 of the microsomal ethanol
oxidizing system (MEOS). In the third pathway, catalase oxidizes ethanol to acetaldehyde with
concomitant reduction of hydrogen peroxide (H2O2) to H2O.The intermediate acetaldehyde is further
reduced by acetaldehyde dehydrogenase in a reaction that also produces NADH. Together,
acetaldehyde and NADH create most of the havoc that gives rise to alcoholic steatosis.

Fatty acids have alternate fates in the normal liver
You have learned in BMB 515 and PSL 539 that, once in the liver, free fatty acids (FAs) have several
different fates (Fig. 2A). For example, the FAs can undergo -oxidation to acetyl-CoA. Acetyl-CoA can,
in turn, enter into one of several pathways, including the TCA cycle, ketone body synthesis, or
cholesterol synthesis.

Alternatively, in the presence of glycerol 3-phosphate (-glycerophosphate), the FAs may be

incorporated into the glycerol backbone to form phosphatidic acid, which is the precursor to both
phospholipids and triglycerides (TGs). Little TG is stored in the healthy liver. Instead, most is packaged
with other lipids and apolipoproteins into lipoprotein particles such as VLDL. VLDLs are secreted into
the blood where they function to deliver the lipids to the peripheral tissues (Fig. 2A).

Ethanol metabolism changes fatty acid metabolism in the liver

Via transcriptional regulation, acetaldehyde, derived from alcohol metabolism, increases FA synthesis.
Exacerbating this situation is the fact that TNF-, released by Kupffer cells as a part of the immune
response to ethanol intoxication, also stimulates FA synthesis. Concomitantly, the utilization of FAs
(e.g. -oxidation) is inhibited by high levels of NADH (Fig. 2B), produced by both steps of the ADH
pathway (Fig. 1). Moreover, acetaldehyde also decreases the expression of the enzymes needed for -
oxidation. Thus, FAs accumulate to even higher levels.

Figure 2 Hepatocellular lipid metabolism and the effect of alcohol

In the meantime, there is also elevation of glycerol 3-phosphate (-glycerophosphate) in the liver as a
result of: (a) high NADH levels driving the conversion of the glycolytic intermediate dihydroxyacetone
phosphate to glycerol 3-phosphate; and (b) influx of glycerol 3-phosphate from adipose tissue via the
bloodstream. Since FAs and glycerol 3-phosphate are the two principal substrates for the biosynthesis
of TGs, they contribute to the accumulation of TGs in the liver. Lastly, ethanol inhibits apolipoprotein
synthesis which interferes with the export of TGs (in the form of lipoproteins) out of the liver (Fig. 2B).

In summary, elevated NADH and acetaldehyde lead to steatosis (abnormal retention of lipids) by
causing: (a) mobilization of fat stores in adipose tissue with the resulting FA transported to the liver and
increased FA synthesis in the liver; (b) inhibition of FA oxidation in the liver; (c) increased TG synthesis;
and (d) decreased availability of apolipoproteins for export of TG out of the liver.

PATHOLOGIC CHARACTERISTICS

Microscopic Changes

The pattern of injury induced by alcohol intake is designated macrovesicular steatosis, reflecting the
formation of large, lipid-filled vesicles within the hepatocyte and the subsequent peripherilization of
nuclei (Fig. 3). Steatosis begins in the perivenular hepatocytes, around the central veins (CV in Fig 3).
On progression, steatosis extends to all hepatocytes in the lobule. Macrovesicular steatosis is
considered a benign condition because it is completely reversible after four or more weeks of continued
abstinence from alcohol.
Figure 3

Figure 3 Liver biopsy

specimen demonstrating
macrovesicular steatosis in a
chronic alcohol user. The
microscopic images shown
in A and B are low- and high-
power views of the same H &
E-stained biopsy sample.
(CV, central vein)

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Gross Changes

In AS, the macroscopic changes that may be observed with the liver include:
hepatomegaly
soft with smooth borders
yellowish in color

CLINICAL FEATURES

Physical exam and history

Despite the striking morphologic changes that can be observed with the liver, individuals with AS have
surprisingly few outward symptoms. In fact, most are asymptomatic. The diagnosis is often made during
a routine office visit for an entirely unrelated matter.
In some cases, the physical exam reveals hepatomegaly.
Patients that are not asymptomatic may present with any of the following:
vague discomfort in the right upper quadrant (RUQ) of the abdomen
mild nausea
general feeling of un-wellness
It is important to note that steatosis caused by alcohol is histologically identical to steatosis due to other
non-alcoholic causes,likediabetes mellitus, obesity, exposure to environmental toxins such as dioxin,
commonly referred to as non-alcoholic fatty liver disease (NAFLD). Therefore a careful patient history,
establishing or ruling out significant alcohol intake, is required to make the diagnosis.

Laboratory findings
In individuals with AS, the results of liver function tests and other laboratory findings are usually non-
specific or within normal ranges. You will learn more about liver function tests when your classmates
discuss alcoholic hepatitis.

OPPORTUNITIES TO CONFIRM UNDERSTANDING

Practice Questions (with Answers below)

1) Name the two enzymes principally responsible for metabolizing ingested alcohol into acetate.

2) When large amounts of ethanol are ingested (or with chronic consumption of alcohol), what other
enzyme system can be induced to metabolize the alcohol?

3) What is the basis for fat accumulation in the liver after alcohol consumption?

4) What does fatty liver look like?

5) A 52-year-old man was admitted to the ED in a coma. He had been a moderate drinker but his
consumption of alcohol had increased markedly following the death of his wife one month ago.
His married daughter dropped in to see him on Sunday morning and found him unconscious on the

 couch. On examination, alcohol could be smelled on his breath; his breathing was deep and noisy;
and his temperature was 35.5 oC (normal: 36.3 37.1). Pertinent laboratory results include: (a)
glucose 2.7 mmol/L (normal: 4.2-6.2); (b) lactate 8.0 mmol/L (normal: 0.5 1.6); and (c) blood pH
7.21 (normal: 7.35-7.45). The inhibition of which of the following biochemical pathways is most
directly responsible for the observed lactic acidosis: glycolysis, gluconeogenesis, glycogenolysis,
and glycogenesis?

6) A 25-year-old male with a history epilepsy was brought to the ED after convulsing for over an
hour. He had just graduated from medical school and was celebrating the night before by going on
an alcohol binge. His medical records indicate that his seizures had been controlled with anti-
seizure medication for the past three years. There had been no interruption in the medication
regimen, change of brand or dose. The emergency room physician wrote him a prescription for the
same anti-seizure medication, but at a higher dose than before and released him. What could have
happened to cause seizures in this individual?

Answers to Practice Questions

1) Alcohol dehydrogenase (ADH) and acetaldehyde dehydrogenase sequentially convert alcohol to

acetaldehyde and the latter to acetate.

2) The microsomal ethanol oxidizing system (MEOS), which utilizes CYP2E1, can be activated.

3) Hepatocytes constitute a common site for fat accumulation because they play a central role in fat
metabolism. Fatty acids in the liver are derived from dietary sources (coming as triglycerides and
chylomicrons), from adipose tissue, and from de novo synthesis via acetyl-CoA. At the same time,
-oxidation of fatty acids in the liver is inhibited by the high levels of NADH produced by alcohol
metabolism. So the fatty acids are esterified into triglycerides. Because there is decreased
availability of apolipoproteins to transport the triglycerides out of the liver, the latter accumulate as
fat vesicles.

4) Gross: liver appears enlarged, develops rounded edges, becomes yellowish and feels greasy.
Microscopic: large, lipid-filled vesicles form in the hepatocyte with peripherilization of nucleus.
Macrovesicular steatosis begins in the hepatocytes around the central veins and eventually extends
to all the hepatocytes in the lobule.

5) The metabolism of ethanol by alcohol dehydrogenase and acetaldehyde dehydrogenase drastically

increases the NADH/NAD+ ratio, which favors lactate over pyruvate in the lactate dehydrogenase
reaction. This depletes the substrate for the pyruvate carboxylase reaction that initiates
gluconeogenesis. If liver glycogen has been depleted, this inhibition of gluconeogenesis results in
hypoglycemia as was observed in the patient.

6) Alcohol induced the upregulation of CYP2E1, a member of the cytochrome P450 mixed-function
oxidase system that is involved in the metabolism of xenobiotics (foreign substance not normally
bound in an organism) in the body. The anti-seizure medication got cleared from the body of the
newly-minted doctor much faster than normal and could no longer control the seizure. So, the
emergency room physician simply had to up the dose and instruct him to follow-up with the regular
physician.