What is the examination protocol for patients suspected of having alcoholic liver disease?

Examination Protocol for Alcoholic Liver Disease

Use non-invasive assessment with FibroScan® or specialized blood tests (FibroTest® or FibroMeter Alcohol®) as first-line evaluation for fibrosis staging in all patients with suspected alcoholic liver disease, while avoiding reliance on transaminases alone for screening. 1

Initial Clinical Assessment

History and Physical Examination

• Document alcohol consumption history: Quantify daily intake (>30 g/day suggests risk for ALD), duration of use, and pattern of drinking 1, 2
• Screen for alcohol use disorder: Apply the AUDIT questionnaire (positive if score ≥8 for men up to age 60, or ≥4 for women, adolescents, or men over 60) 3
• Physical findings to assess:
  • Bilateral parotid gland hypertrophy, muscle wasting, malnutrition, Dupuytren's contracture, symmetric peripheral neuropathy 1
  • In advanced disease: gynecomastia, extensive spider angiomas, jaundice, ascites 1
  • Signs of portal hypertension and hepatic decompensation 2

Laboratory Evaluation

Standard Blood Tests

• AST and ALT: AST/ALT ratio >2 is highly suggestive of ALD, with ratios >3 being even more specific 3
• Important caveat: AST levels rarely exceed 300 IU/ml in ALD; levels >500 IU/L or ALT >200 IU/L suggest alternative etiologies 3
• GGT and MCV: The combination of elevated GGT and elevated MCV improves sensitivity for diagnosing alcohol abuse, though GGT alone has limited specificity 3
• Complete blood count: Assess for thrombocytopenia (suggests advanced disease) and macrocytosis 3
• Liver synthetic function: Albumin, prothrombin time/INR, bilirubin 1

Critical Limitation

Do not use transaminases alone for screening advanced alcohol-related liver disease—40-74% of patients with advanced fibrosis have normal ALT levels. 1

Non-Invasive Fibrosis Assessment (First-Line)

Recommended Methods

Perform FibroScan® (transient elastography) OR specialized blood tests (FibroTest® or FibroMeter Alcohol®) in all patients with suspected ALD. 1

• FibroScan® interpretation: Apply specific thresholds based on concurrent AST and bilirubin levels at time of measurement 1
• These methods detect advanced fibrosis/cirrhosis with ~95% accuracy 4
• APRI score is NOT recommended for fibrosis assessment in ALD 1

Additional Testing

• Exclude other liver diseases: Test for hepatitis B and C, autoimmune markers, iron studies, ceruloplasmin 3
• Direct alcohol biomarkers (if available):
  • Ethyl glucuronide (EtG) in urine detects use for 3-4 days 3
  • Hair EtG detects chronic excessive consumption (>30 pg/mg indicates chronic excessive use) 3

Liver Biopsy Indications

Reserve liver biopsy for specific clinical scenarios, not routine evaluation. 1

When to Perform Biopsy

• Suspected alcoholic hepatitis requiring specific treatment (corticosteroids/pentoxifylline) 1
• Discordant non-invasive test results casting doubt on presence of cirrhosis 1
• Suspected coexisting chronic liver disease (up to 20% have competing etiologies) 3
• Atypical presentation with confounding factors 1

Biopsy Technique

• Use transjugular approach in patients with coagulopathy, thrombocytopenia, or ascites 1
• Percutaneous biopsy acceptable only if coagulation parameters and platelets are adequate 1

Alcoholic Hepatitis Evaluation

Clinical Diagnosis Classification (NIAAA)

Apply the NIAAA classification system when alcoholic hepatitis is suspected: 1

1. Definite AH: Clinically diagnosed AND biopsy proven
2. Probable AH: Heavy alcohol use + typical liver tests without confounding factors (misdiagnosis risk <10%)
   • AST 50-400 IU/ml
   • AST/ALT ratio ≥1.5
   • Clear alcohol history
3. Possible AH: Confounding factors present OR atypical labs (AST <50 or >400 IU/ml, AST/ALT <1.5) OR uncertain alcohol history
   • Requires liver biopsy for confirmation 1

Severity Assessment

Calculate Maddrey Discriminant Function and MELD score to identify severe forms: 1

• Maddrey score ≥32: Defines severe alcoholic hepatitis requiring corticosteroid consideration
• MELD score 17-20: Alternative threshold for severe disease
• Note: Even Maddrey <32 carries ~20% 1-year mortality, so avoid labeling as "non-severe" 1

Imaging Studies

• Abdominal ultrasound: Assess liver echogenicity, size, nodularity, portal vein patency, ascites, splenomegaly 4
• Controlled Attenuation Parameter (CAP): Insufficient for steatosis assessment in ALD 1
• Advanced imaging (CT/MRI): Reserve for complications or when ultrasound inadequate 4

Common Pitfalls to Avoid

• Normal liver enzymes do not exclude significant ALD—up to 50% of advanced fibrosis cases have normal transaminases 3
• Conventional ultrasound and routine labs miss ~40% of manifest alcoholic cirrhosis 4
• GGT loses specificity in advanced liver disease and becomes elevated regardless of alcohol etiology 3
• AST/ALT ratio becomes less specific in cirrhotic stage 3
• Always screen for coexisting liver diseases—20% have additional etiologies 3

Additional Assessments

• Screen for cognitive impairment: High prevalence in alcohol use disorder 1
• Assess for metabolic syndrome: Obesity and metabolic factors accelerate ALD progression 1
• Evaluate smoking status: Increases fibrosis and HCC risk 1
• Consider addiction liaison team involvement for comprehensive care 1