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Alcohol-related liver disease

Definition
ALD encompasses a spectrum of disorders that may take an acute form (alcoholic hepatitis) or present as a chronic disease (steatosis, steatohepatitis, fibrosis, and cirrhosis).
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Pathophysiology
ALD is caused by heavy alcohol use.
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Disease course
Alcohol abuse results in steatosis followed by steatohepatitis, alcoholic hepatitis, fibrosis, and liver cirrhosis due to inflammation, hepatocellular damage, and liver fibrosis. Disease progression may also cause liver decompensation and HCC.
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Prognosis and risk of recurrence
The 1-year mortality of ALD as a single group is around 20%.
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Key sources
The following summarized guidelines for the evaluation and management of alcohol-related liver disease are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2024; 2022; 2018), the European Association for the Study of the Liver (EASL 2023; 2018), the French Society of Alcohology (SFA/AFEF 2022), the American Association for the Study of Liver Diseases (AASLD 2020), and the U.S. Preventive Services Task Force (USPSTF 2018).
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Guidelines

1.Screening and diagnosis

Screening for alcohol abuse: as per ACG 2024 guidelines, implement standardized screening practices for alcohol use disorder at every medical encounter across diverse clinical settings, including primary care, with attention to conducting screening in a nonbiased manner.
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  • Screening for ALD

  • Diagnosis

2.Classification and risk stratification

Risk factors: recognize that:
the amount and duration of alcohol use are the primary risk factors for the development of alcohol-associated liver disease
daily heavy alcohol use and binge alcohol use increase the risk of advanced liver disease in patients with liver disease other than alcohol-associated liver disease, such as metabolic dysfunction-associated steatotic liver disease and viral hepatitis
insufficient evidence to determine whether binge drinking without daily heavy use predisposes to advanced forms of alcohol-associated liver disease
all types of alcohol increase the risk of liver disease; however, limited data suggest that risk may be higher with liquor as opposed to beer or wine
genetic variants of AAT, PNPLA3, TM6SF2, and MBOAT7 have been associated with risk of alcohol-associated liver disease
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  • Prognostic scores

3.Diagnostic investigations

Initial evaluation
Obtain noninvasive blood and/or imaging studies to assess the severity of fibrosis in patients with asymptomatic ALD. Use the Fibrosis-4 score, a blood-based marker, and hepatic transient elastography for fibrosis detection in patients with ALD.
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Counsel patients with heavy drinking with evidence of ALD detected with noninvasive tests regarding the risk of progressive liver disease and refer them to a hepatology specialist for further management.
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  • Assessment of liver fibrosis

  • Evaluation for advanced disease

  • Screening for infection

  • Screening for cognitive impairment

4.Diagnostic procedures

Liver biopsy
As per ACG 2024 guidelines:
Do not perform liver biopsy to make a diagnosis of alcohol-associated hepatitis in the absence of confounding factors or for staging fibrosis.
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Consider performing a liver biopsy in case of diagnostic uncertainty based on noninvasive assessment.
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5.Medical management

General principles
As per ACG 2024 guidelines:
Manage patients with ALD cirrhosis similar to cirrhosis due to other causes.
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Manage patients with severe alcohol-associated hepatitis (MELD > 20) preferably in a hospital setting because of a high short-term mortality.
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  • Management of alcohol use disorder

  • Management of alcohol withdrawal

  • Corticosteroids

  • N-acetylcysteine

  • Antibiotic prophylaxis

  • Pentoxifylline

  • G-CSF

  • Microbiome-based therapy

6.Nonpharmacologic interventions

Alcohol abstinence: as per AFEF 2022 guidelines, advise patients with cirrhosis and/or HCC to completely and permanently stop all alcohol consumption in order to limit the risk of excess mortality.
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  • Brief behavioral intervention

  • Smoking cessation

  • Weight loss

  • Nutritional support

7.Perioperative care

Pretransplantation care: decide on the duration of abstinence before listing depending on the degree of liver insufficiency in selected patients with a favorable addiction and psychological profile and supportive relatives.
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8.Surgical interventions

Liver transplantation: as per ACG 2024 guidelines, consider offering early liver transplantation in highly selected patients with severe alcohol-associated hepatitis not responding to medical management with a high risk of death, according to regional and institutional protocols.
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9.Specific circumstances

Pregnant patients: advise delaying conception until abstinence is achieved in female patients with ALD.
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  • Patients with acute-on-chronic liver failure

10.Preventative measures

Alcohol restriction: as per ACG 2024 guidelines, advise alcohol avoidance in patients with obesity.
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11.Follow-up and surveillance

Monitoring of abstinence: consider obtaining hair or urine ethyl glucuronide for accurate monitoring of abstinence in patients with ALD.
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  • Monitoring of transplant recipients

12.Quality improvement

Public health measures: as per ACG 2024 guidelines, implement public policy interventions to reduce the burden of alcohol use disorder and alcohol-associated liver complications, as well as alcohol-related morbidity and mortality.
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