What is the management of alcoholic liver injury?

Management of Alcoholic Liver Injury

The cornerstone of management for alcohol-related liver disease (ARLD) is complete and sustained alcohol abstinence, which is the most effective intervention to reduce liver-related complications and mortality. 1, 2

Initial Assessment and Diagnosis

• Systematic alcohol consumption assessment must be performed in both general practice and specialist consultations to identify patients at risk 3
• Comprehensive evaluation using non-invasive methods such as transient elastography (Fibroscan) should be conducted to assess the severity of liver damage and identify patients with advanced fibrosis or cirrhosis 2
• Laboratory assessment should include liver function tests, with particular attention to serum bilirubin >3.0 mg/dL, AST >50 IU/L but <400 IU/L, and AST/ALT ratio >1.5 1
• Screening for cofactors that may worsen liver injury, including obesity, insulin resistance, viral hepatitis, and iron overload is essential 2

Management Algorithm

1. Alcohol Abstinence Interventions

• Complete abstinence from alcohol is essential for all patients with ARLD, regardless of disease stage 1, 2
• Management should involve an addiction specialist along with psychosocial support 2
• Pharmacotherapy options to support abstinence include:
  • Acamprosate for supporting continuous abstinence in alcohol-dependent patients 2, 4
  • Baclofen, which has shown benefit in achieving and maintaining abstinence in patients with cirrhosis 2
  • Naltrexone may be considered but should be used with caution due to potential hepatotoxicity 2, 3

2. Nutritional Support

• Aggressive nutritional therapy is recommended with daily energy intake of 35-40 kcal/kg and protein intake of 1.2-1.5 g/kg 2
• Supplement with B-complex vitamins to prevent Wernicke's encephalopathy 2
• Consider enteral nutrition via feeding tube if patients cannot maintain adequate oral intake 2

3. Disease-Specific Management

For Alcoholic Hepatitis

• Severity assessment using validated scoring systems like Maddrey discriminant function (MDF >32) or MELD score (>20) should be performed 1
• For severe alcoholic hepatitis, first-line treatment is corticosteroids (prednisolone 40 mg/day or methylprednisolone 32 mg/day) for 28 days, with response assessment at day 7 using the Lille score 1
• N-acetylcysteine combined with corticosteroids may be considered for patients with contraindications to corticosteroids 1
• Systematic screening for infections, including blood cultures, urine cultures, and ascites fluid culture (if present), is mandatory before initiating treatment 1

For Alcoholic Cirrhosis

• Implement standard management for complications of cirrhosis, including:
  • Treatment of hepatic encephalopathy with lactulose and rifaximin 2
  • Management of ascites with salt restriction 2
  • Prevention of variceal bleeding (note: use beta-blockers cautiously due to risk of acute kidney injury) 2
• Consider liver transplantation evaluation for patients with advanced cirrhosis who demonstrate sustained abstinence 2, 4

Monitoring and Follow-up

• Regular monitoring of liver function tests to assess improvement with abstinence 2
• Use transient elastography (Fibroscan) to monitor changes in liver fibrosis 2
• Combining the Lille and MELD scores provides optimal prediction of short and medium-term mortality risk in alcoholic hepatitis 1
• Screen for and manage extrahepatic alcohol-related damage, including cardiomyopathy, pancreatitis, and neurological complications 2

Common Pitfalls and Caveats

• The immune response is impaired in patients with alcoholic hepatitis, placing them at high risk for bacterial and fungal infections 1
• Development of multi-organ failure is associated with very high mortality 1
• Corticosteroid therapy improves short-term (28-day) survival but shows no significant benefit at 3 months and beyond 1
• Avoid nephrotoxic drugs and use caution with diuretics to prevent acute kidney injury 2
• Use caution with paracetamol in patients with ALD cirrhosis, particularly when malnourished 2
• Long-term outcomes depend primarily on maintaining abstinence, with medical treatment responders having 5-year survival rates of approximately 80% if abstinence is maintained, versus approximately 50% with alcohol relapse 1