Alcohol-related liver disease
Spectrum: steatosis → AH → cirrhosis. Harmful drinking: ≥3/d men, ≥2/d women (or binge). AUDIT-C screen.
Spectrum — steatosis to hepatitis to cirrhosis
Women more susceptible than men. Pattern (daily + binge), obesity, diabetes, PNPLA3, α1-antitrypsin, smoking, HCV/MASLD raise risk; coffee lowers it (: ; ACG: ). Harmful drinking: men ≥3 drinks/d or ≥21/week; women ≥2/d or ≥14/week. AUDIT-C everyone.
1
Steatosis
Usually asymptomatic; mild AST > ALT and GGT. 90% after >60 g/d for 2 weeks. Reverses with 4–6 weeks of abstinence. 20–40% → fibrosis → 8–20% cirrhosis → 20–40% decompensation/ACLF; HCC in 3–10% of cirrhotics.
2
Steatohepatitis / AH
Histologic correlate of alcohol-associated hepatitis. Can appear at any fibrosis stage. 40–50% already fibrotic; >75% headed toward cirrhosis.
3
Cirrhosis
Architectural distortion and portal hypertension. 5-year liver mortality ~25%. Treatment of the disease is cessation of alcohol.
- Counsel with the 5 As (ask, advise, assess, assist, arrange). Pharmacotherapy: baclofen, acamprosate, naltrexone, gabapentin, topiramate. Avoid disulfiram in liver disease.
- AH can generate acute portal hypertension (varices, ascites, HE) without established cirrhosis because the liver is swollen.
Alcohol-associated hepatitis — diagnose, then score
Jaundice within 8 weeks of ongoing heavy use (women >3, men >4 standard drinks/day for >6 months), <60 days of abstinence before jaundice, AST 50–400 with AST/ALT >1.5, total bilirubin >3. Often leukocytosis <20k (PMN-predominant) and a rising INR. Tender hepatomegaly, anorexia, fever, malaise.
- Exclude viral hepatitis, APAP, ischemia, AIH, Budd-Chiari, biliary obstruction, and decompensated cirrhosis (superimposed in 10–20%). HAV/HBV/HCV, APAP level, Doppler US, ± ANA/ASMA/IgG/AMA.
- Transjugular biopsy if atypical (AST/ALT >400), uncertain drinking history, jaundice >3 months, or competing toxin/ischemia.
- Screen infection even if SIRS is ‘just inflammation’ — 12–26% of severe AH are infected on arrival.
| Score | Job | Parts | Cut |
|---|---|---|---|
| Maddrey DF | Who might benefit from steroids | PT, control PT, bilirubin | ≥32 = severe; 1-month mortality 30–50% () |
| MELD | Admission and 90-day death | Bili, INR, Cr, Na | >20: admit, GI for steroids; 3-month mortality ~20% () |
| Lille | Is the steroid working? | Age, albumin, PT, Cr, serial bili days 0/4/7 | ≥0.45 at day 4 or 7 = nonresponse → stop () |
STOPAH, nutrition, early transplant
If MDF ≥32 or MELD 20–50 and no steroid contraindication (uncontrolled diabetes, UGIB, infection, Cr >2.5, / multi-organ failure, untreated HBV/HCV/DILI/HCC/pancreatitis/HIV/TB): prednisolone 40 mg daily (methylprednisolone 32 mg IV). (): possible 28-day mortality signal, none at 90 days, more infection. Pentoxifylline does not death.
- Lille ≥0.45 → stop steroids. Lille <0.45 → complete 28 days then a 2–4 week taper.
- NAC with steroids × 5 days may lower 1-month mortality, not 3- or 6-month (). Large volume load.
- Hold beta-blockers if MDF ≥32 (↑ AKI; ).
- Nutrition is disease-modifying: 35 kcal/kg/d and 1.2–1.5 g/kg protein; thiamine, folate, MVI, B6, B12, zinc. Low intake predicts infection (). Tube-feed if <21 kcal/kg/d.
- G-CSF and fecal transplant are experimental. Nonresponders: early transplant discussion or palliation (especially ≥3 organ failures).