Editors

PanuK.Luukkonen

PerttuSahlman

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

For diagnosis, a history of high alcohol consumption and clinical or biological proof of liver damage is required.
- Alcohol history
- Proof of high alcohol consumption
  - AUDIT test to assess alcohol consumption
  - If the alcohol history remains uncertain or unreliable, other indicators can be used, as necessary.
    - Direct alcohol markers (breath alcohol, serum ethanol, blood phosphatidylethanol)
    - Indirect alcohol markers (AST/ALT ratio, MCV, CDT) are low in sensitivity and should therefore be combined with other laboratory tests, history and clinical findings
    - See also Recognition of alcohol and drug abuse Recognition of Alcohol and Drug Abuse
Workup
- Basic tests when suspecting ALD (Basic blood count with platelet count, plasma ALT, AST, ALP, bilirubin, prothrombin time or INR, albumin, serum prealbumin, plasma potassium, sodium, creatinine, and fasting glucose)
- Upper abdominal ultrasonography
- Tests for alternative or concomitant causes T1. See also article on Assessing patients with abnormal liver function test results Assessing a Patient with an Abnormal Liver Function Test Result.
Detecting concomitant risk factors for liver disease
- Family history of cirrhosis, obesity Assessment of an Obese Patient, metabolic syndrome Metabolic Syndrome, diabetes Comprehensive Treatment and Follow-Up of Type 2 Diabetes, different types of viral hepatitis Viral Hepatitis, hepatotoxic medication (see locally available drug database), natural products and smoking
Detecting alcoholic hepatitis
- Acute jaundice, liver failure, general symptoms, resulting from excessive drinking
- Patients with alcoholic hepatitis need emergency specialized care.
Detecting liver cirrhosis
- See also Cirrhosis of the liver Cirrhosis of the Liver.
- Clinical signs of liver cirrhosis
  - Spider naevi, palmar erythema, jaundice, ascites, muscular wasting
- Some patients with cirrhosis may be asymptomatic and may have normal liver enzyme values. Detecting such ‘silent' cirrhosis is essential for the prognosis and for screening for complications particularly in heavy drinkers.
  - Markers of fibrosis, Fibrosis-4 index (i.e. FIB-4 index http://www.mdcalc.com/fibrosis-4-fib-4-index-liver-fibrosis), aspartate aminotransferase to platelet ratio index (APRI, i.e. AST/platelet index http://www.mdcalc.com/ast-platelet-ratio-index-apri), should be used only after due consideration because they have not been separately validated for alcoholic liver disease, and alcohol consumption as such may lead to inaccurate values.
  - Elastography (if available)
- Screening for complications
  - Oesophageal varices Haematemesis (gastroscopy), hepatocellular carcinoma Cancer of the Liver and the Biliary Tract (ultrasonography)
  - Assessment of nutritional status
    - The aim is to eat several meals a day, 35 kcal/kg/day of energy and 1.2-1.5 g/kg/day of protein.
  - Detection of other diseases associated with ALD
    - GI cancers Colorectal Cancer, cancers in the head and neck regions Cancers of the Head and Neck, respiratory tract cancers Lung Cancers, alcohol-related neurological diseases Neurological Disorders and Alcohol, dilated cardiomyopathy Dilated Cardiomyopathy, hypertension Hypertension: Investigations, Treatment Initiation and Non-Pharmacological Treatment, arrhythmias Symptoms of Arrhythmia and Examination of an Arrhythmia Patient

Treatment

The most important treatment improving the prognosis is stopping alcohol consumption.
- This will improve the prognosis at any stage of the disease.
- It will reverse histological changes in the liver.
- A mini intervention Brief Interventions for Risky Use of Alcohol should be performed for all heavy users.
- Appropriate patients should be referred for substance abuse treatment Providing Care for an Alcohol or Drug Abuser Drugs Used in Alcohol Dependence
- See also Pharmacotherapy in alcohol dependence Drugs Used in Alcohol Dependence.
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.

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 score 1http://www.mdcalc.com/child-pugh-score-cirrhosis-mortality	Ascites
			Encephalopathy

References

Singal AK, Bataller R, Ahn J et al. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol 2018;113(2):175-194. [PubMed]http://journals.lww.com/ajg/fulltext/2018/02000/acg_clinical_guideline__alcoholic_liver_disease.9.aspx
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. [PubMed]http://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.30866
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. [PubMed]http://doi.org/10.1016/j.jhep.2018.10.041
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. [PubMed]http://doi.org/10.1016/j.jhep.2018.03.018
Friedman SL. Management of alcohol-associated steatosis and alcohol-associated cirrhosis. UpToDate. http://www.uptodate.com/contents/management-of-alcohol-associated-steatosis-and-alcohol-associated-cirrhosis (accessed 16.10.2021) http://www.uptodate.com/contents/management-of-alcohol-associated-steatosis-and-alcohol-associated-cirrhosis/print?search=Alcoholic%20liver%20disease&topicRef=3617&source=see_link
Friedman SL. Clinical manifestations and diagnosis of alcohol-associated fatty liver disease and cirrhosis. UpToDate. http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-alcohol-associated-fatty-liver-disease-and-cirrhosis (accessed 16.10.2021) http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-alcohol-associated-fatty-liver-disease-and-cirrhosis/print?search=Alcoholic%20liver%20disease&source=search_result&selectedTitle=1~150&usage_type=default&display_ra

section name header

Information

Editors

Alcoholic Liver Disease (Ald)

Essentials

Examination and diagnosis

Treatment

Consulting specialized care

Workup in patients with alcoholic liver disease

References