Alcoholic liver disease

Introduction

ARLD is a progressive spectrum ranging from simple steatosis to alcoholic hepatitis and, ultimately, cirrhosis. Sustained abstinence halts or reverses early disease, whereas continued drinking leads to irreversible damage and high mortality.

Epidemiology

• Peak presentation 40 – 60 years; incidence parallels population alcohol consumption.
• Risk rises with > 35 units week⁻¹ (women) or > 50 units week⁻¹ (men), but genetic and nutritional factors modulate susceptibility.

Pathogenesis

• Excess ethanol metabolism generates acetaldehyde and reactive oxygen species, provoking hepatic steatosis, inflammation and fibrosis.
• Co-factors that accelerate progression include obesity, chronic hepatitis C, iron overload and female sex.

Clinical Presentation

Investigations

Complications

• Decompensated cirrhosis: ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, variceal bleeding, hepatorenal syndrome.
• Hepatocellular carcinoma (annual incidence 3 – 5 % in cirrhotics).
• Extra-hepatic: malnutrition, osteoporosis, pancreatitis, Wernicke–Korsakoff syndrome.

Management

1. Alcohol cessation

• Brief intervention, motivational interviewing and referral to specialist alcohol services.
• In-patient withdrawal: chlordiazepoxide regimen + high-dose IV Pabrinex® for 3 days.
• Relapse-prevention drugs (after abstinence ≥ 5 days and when not cirrhotic decompensated): acamprosate or disulfiram; baclofen an option in cirrhosis.

2. Nutritional optimisation

• High-protein, high-calorie diet (35–40 kcal kg⁻¹ day⁻¹, 1.2–1.5 g protein kg⁻¹ day⁻¹).
• Daily vitamins: thiamine 100 mg oral (after IV course), folate, fat-soluble vitamins, zinc if deficient.

3. Alcoholic hepatitis

• Assess severity (Maddrey DF, MELD).
• Prednisolone 40 mg daily for 28 days if DF ≥ 32 and no sepsis/GI bleed; calculate Lille score day 7 to decide continuation.
• Consider early transplant referral for non-responders (Lille > 0.45).

4. Cirrhosis complication management

• Ascites: salt restriction < 2 g day⁻¹, spironolactone : furosemide 100 : 40 mg; large-volume paracentesis + albumin if tense.
• Varices: non-selective β-blocker (carvedilol 12.5 mg od) or endoscopic band ligation; terlipressin + antibiotics for acute bleed.
• Encephalopathy: lactulose titrated to 2–3 soft stools day⁻¹ ± rifaximin 550 mg bd.
• Hepatorenal syndrome: albumin challenge then vasoconstrictor (terlipressin) and ICU/renal liaison.

5. Vaccination & prophylaxis

• Offer hepatitis A, B and pneumococcal vaccines; prescribe proton-pump inhibitor if variceal bleed risk.

6. Liver transplantation

• Indicated for decompensated cirrhosis or steroid-non-responsive severe alcoholic hepatitis after multidisciplinary assessment and documented period of motivated abstinence (usually 3–6 months, but early listing considered in selected cases).

Monitoring & Follow-up

• 3-monthly LFTs, clotting and ultrasound / AFP every 6 months once cirrhotic.

• Repeat FibroScan annually in abstinent, non-cirrhotic patients.

• Ongoing support for alcohol abstinence and mental health.