How to treat decompensated alcoholic liver disease?

Treatment of Decompensated Alcoholic Liver Disease

Complete abstinence from alcohol is the cornerstone of treatment for decompensated alcoholic liver disease and represents the most important therapeutic goal to reduce the risk of complications and mortality. 1, 2

Initial Management Approach

Alcohol Abstinence

• Implement complete and permanent cessation of alcohol consumption
• Refer to addiction specialists for:
  • Motivational therapy
  • Anti-craving medications (baclofen is considered safe in advanced liver disease) 1
  • Psychosocial support

Nutritional Support

• Provide aggressive nutritional therapy rich in calories and proteins 1
• Implement frequent interval feedings with emphasis on nighttime snack and morning feeding 1
• Consider enteral nutrition in severely malnourished patients 1, 2
• Target supplemental protein and 1000 kcal in decompensated patients 1
• Ensure vitamin and micronutrient supplementation, particularly B vitamins 2

Management of Specific Complications

Ascites

• Restrict sodium intake to 2000 mg/day
• Initiate diuretic therapy:
  • Start with spironolactone (100 mg/day)
  • Add furosemide (40 mg/day) if needed
  • Titrate doses while monitoring electrolytes and renal function
• Perform paracentesis for refractory or tense ascites
• Avoid fluid restriction unless severe hyponatremia (sodium <120-125 mmol/L)

Hepatic Encephalopathy

• Identify and treat precipitating factors
• Administer lactulose (initial dose 25 mL every 1-2 hours until bowel movement, then 25 mL 2-3 times daily)
• Add rifaximin 550 mg twice daily for recurrent episodes 3
• Monitor for improvement in mental status

Variceal Bleeding

• Provide primary prophylaxis with non-selective beta-blockers for patients with varices
• For acute bleeding:
  • Immediate resuscitation and hemodynamic stabilization
  • Endoscopic band ligation or sclerotherapy
  • Vasoactive drugs (terlipressin, somatostatin, octreotide)
• Secondary prophylaxis with combination of beta-blockers and endoscopic band ligation

Alcoholic Hepatitis (if superimposed)

• Assess severity using Maddrey Discriminant Function (MDF) score
• For severe alcoholic hepatitis (MDF ≥32):
  • Consider prednisolone 40 mg/day for 28 days if no contraindications 1
  • Use pentoxifylline 400 mg three times daily for 4 weeks if steroids are contraindicated 1
  • Consider N-acetylcysteine in patients receiving corticosteroids 1
  • Monitor for early non-response to steroids and adjust therapy accordingly 1

Hepatorenal Syndrome

• Avoid nephrotoxic medications
• Maintain adequate intravascular volume
• Consider vasoconstrictors (terlipressin, norepinephrine) with albumin

Screening and Monitoring

• Perform ultrasound examination every 6 months to screen for hepatocellular carcinoma 1, 2
• Monitor for bacterial infections, which are common in alcoholic cirrhosis 1
• Screen for alcohol-induced damage to other organs:
  • Heart (alcoholic cardiomyopathy) 1, 2
  • Kidneys (IgA-induced nephropathy) 1, 2
  • Nervous system (central and peripheral involvement) 1, 2
  • Pancreas (chronic pancreatitis) 1, 2

Liver Transplantation

• Consider liver transplantation for end-stage liver disease 1, 4
• Most programs require 6-month abstinence period prior to evaluation 2
• Early liver transplantation may be appropriate in highly selected patients with severe alcoholic hepatitis who do not respond to medical therapy 4

Prognosis and Pitfalls

Prognosis

• 1-year and 5-year mortality risks are approximately 30% and 60%, respectively 1
• Hepatic encephalopathy is associated with highest mortality among complications 1
• Ten-year survival is 88% among abstinent patients versus 73% for those who relapse 4

Common Pitfalls

• Failing to address alcohol use disorder as a primary issue
• Inadequate nutritional support despite its critical importance
• Overlooking extrahepatic manifestations of alcohol-related damage
• Delaying referral for liver transplantation evaluation
• Inappropriate use of medications that may worsen liver function
• Underestimating the risk of bacterial infections in these patients

Ineffective Treatments to Avoid

• S-adenosyl-L-methionine (SAMe) 1
• Propylthiouracil 1
• Colchicine 1
• Anabolic-androgenic steroids 1
• Silymarin 1