Alcoholic liver disease (ALD)

Essentials

  • ALD is a continuum from fatty liver to steatohepatitis and liver cirrhosis.
  • ALD increases the risk of hepatocellular carcinoma, and some patients develop acute alcoholic hepatitis resulting from a drinking spree.
  • The risk limit for alcohol consumption is 20 g a day of absolute alcohol for women and 30 g for men – however, there are no completely safe limits for alcohol consumption.
  • Binge drinking is harmful regardless of the average alcohol consumption.
  • The aim is to recognize early stages of alcoholic liver disease, to stop alcohol consumption in time before the disease progresses and to treat complications of advanced disease.
  • A person may have several risk factors for liver disease (such as alcohol and obesity), which should be treated simultaneously. Alcohol also speeds up the progression of liver damage from other causes (NAFLD, chronic viral hepatitis).
  • See also the article Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) (Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)).

Examination and diagnosis

Treatment

  • The most important treatment improving the prognosis is stopping alcohol consumption.
  • Management of concomitant risk factors of liver disease
    • Weight reduction, avoiding medication and natural products that put a strain on the liver, smoking cessation
  • Treatment plans for patients with mild disease should be made in primary health care.
    • If drinking continues, about 20% of patients with ALD will develop cirrhosis.
    • The aim of follow-up is to motivate patients to reduce their alcohol consumption and to detect any signs of progressive disease or complications requiring treatment.

Consulting specialized care

  • Specialized care should be consulted if the patient has signs of progressed disease.
    • Clinical or biochemical signs, imaging or elastography
  • In specialized care
    • Confirming the diagnosis in unclear cases
      • Elastography; liver biopsy, as necessary
    • Planning the treatment of progressed disease and guidance for further follow-up in primary health care
      • Exclusion of hepatocellular carcinoma (ultrasonography)
      • Screening for, and treatment of, oesophageal varices (gastroscopy)
      • Treatment of other complications of portal hypertension (ascites, encephalopathy, hepatorenal syndrome)
      • Assessment of the possibility of liver transplantation in selected patients who were capable of stopping their alcohol consumption and whose liver cirrhosis remains decompensated (ascites, jaundice, encephalopathy, recurrent bleeding from oesophageal varices) despite abstinence
  • Consultation of an addiction medicine specialist and a social worker
  • The prognosis of patients with liver cirrhosis who continue to drink after appropriate primary assessment is very poor, and in most cases they do not benefit from follow-up in specialized care.

Table 1. Workup in patients with alcoholic liver disease
Basic investigations Differential diagnostic tests as considered appropriate Assessment of severity Finding complications in progressed disease
Basic blood count, ALT, AST, ALP, Bil, PT or INR, Alb, Prealb, potassium, sodium, creatinine and fasting glucose HBsAg, anti-HCV antibodies, anti-smooth muscle antibodies, antimitochondrial antibodies, antinuclear antibodies, anti-transglutaminase antibodies, IgG, IgA, IgM, Fe, transferrin saturation level, ferritin, alpha1 antitrypsin (APRI, FIB-4 fibrosis markers as considered appropriate) Oesophageal varices
Upper abdominal ultrasonography Elastography, if available Hepatocellular cancer
In patients with cirrhosis, severity of disease based on the Child–Pugh scorehttps://www.mdcalc.com/child-pugh-score-cirrhosis-mortality Ascites
Encephalopathy

References

1. Singal AK, Bataller R, Ahn J et al. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol 2018;113(2):175-194.  [PMID:29336434] https://journals.lww.com/ajg/fulltext/2018/02000/acg_clinical_guideline__a...
2. Crabb DW, Im GY, Szabo G et al. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020;71(1):306-333.  [PMID:31314133] https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.30866
3. Thursz M, Kamath PS, Mathurin P et al. Alcohol-related liver disease: Areas of consensus, unmet needs and opportunities for further study. J Hepatol 2019;70(3):521-530.  [PMID:30658117] https://doi.org/10.1016/j.jhep.2018.10.041
4. European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu., European Association for the Study of the Liver.. EASL Clinical Practice Guidelines: Management of alcohol-related liver disease. J Hepatol 2018;69(1):154-181.  [PMID:29628280] https://doi.org/10.1016/j.jhep.2018.03.018
5. Friedman SL. Management of alcohol-associated steatosis and alcohol-associated cirrhosis. UpToDate. https://www.uptodate.com/contents/management-of-alcohol-associated-steatosis-and-alcohol-associated-cirrhosis (accessed 16.10.2021) https://www.uptodate.com/contents/management-of-alcohol-associated-steatosis-and-alcohol-associated-cirrhosis/print...
6. Friedman SL. Clinical manifestations and diagnosis of alcohol-associated fatty liver disease and cirrhosis. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-alcohol-associated-fatty-liver-disease-and-cirrhosis (accessed 16.10.2021) https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-alcohol-associated-fatty-liver-disease-and-cirrhosis/print...

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