How do you quantify alcohol consumption in alcohol-related liver disease according to guidelines?

Quantifying Alcohol Consumption in Alcohol-Related Liver Disease

Calculate average daily alcohol intake using the standardized formula: [volume consumed (mL) × alcohol by volume (%) × 0.785 × drinking days per week] ÷ 7, and document this in grams of pure alcohol per day. 1

Standard Calculation Method

The guideline-recommended approach requires collecting specific drinking data and applying a mathematical formula:

• Document the type of alcoholic beverage consumed (beer, wine, spirits, etc.) 1
• Record the volume consumed in milliliters per drinking occasion 1
• Note the alcohol by volume percentage (typically printed on the beverage container) 1
• Count the number of drinking days per week 1

Apply the formula: [volume (mL) × ABV (%) × 0.785] ÷ 100 = grams per occasion, then multiply by drinking days per week and divide by 7 for daily average 1

Practical Example

If a patient drinks one 360 mL bottle of Soju (19% ABV) three times weekly:

• (360 × 19 × 0.785) ÷ 100 = 53.7 g per occasion
• (53.7 × 3) ÷ 7 = 23 g/day average 1

Standard Drink Equivalents

Understanding standard drink definitions is essential, as they vary significantly by country and guideline society. 1, 2, 3

• Korea: 12 g of pure alcohol = 1.5 nips of Soju (90 mL), 1 can of beer (355 mL), 1 bowl of Makgeolli (230 mL), 1 glass of wine (120 mL), or 1 nip of whisky (40 mL) 1
• United States: 14 g of pure alcohol = 12 oz beer, 5 oz wine, or 1.5 oz distilled spirits 1, 2
• United Kingdom: 8 g of pure alcohol per standard drink 3
• Europe: 10 g of pure alcohol per standard drink 3

Diagnostic Thresholds for Alcohol-Related Liver Disease

The commonly applied cutoff for diagnosing ALD is average alcohol intake exceeding 40 g/day in men and 20 g/day in women, though no absolute consensus exists. 1

Risk Stratification by Consumption Level

• Below 40 g/day (men): No significant increase in ALD features in autopsy studies 4
• 40-80 g/day: Increases fatty liver frequency from 11.7% to 47.2% (RR = 4.4) and alcoholic hepatitis to 16.7% (RR = 7.5) 4
• Above 80 g/day: Significantly increases bridging fibrosis and cirrhosis (RR = 8.8) 4
• Above 30 g/day: Risk of ALD substantially increases in both sexes 1

Women develop more severe alcohol-related liver disease at lower doses and are twice as sensitive to alcohol-mediated hepatotoxicity. 3

Validated Screening Tools

Supplement the quantitative calculation with validated questionnaires, as patients frequently underreport consumption. 1

AUDIT-C (Alcohol Use Disorders Identification Test - Consumption)

This 3-question tool is scored 0-12, with >4 positive in men and >3 positive in women. 1

1. How often did you have a drink containing alcohol in the past year? (0-4 points)
2. How many drinks on a typical drinking day? (0-4 points)
3. How often did you have six or more drinks on one occasion? (0-4 points) 1

NIAAA Single Alcohol Screening Question (SASQ)

Ask: "How many times in the past year have you had 4 (women) or 5 (men) or more drinks in a day?" A response of one or more warrants follow-up. 1

Timeline Followback (TLFB)

Use a calendar to accurately record drinking over the past month or other defined interval. 1

Lifetime Drinking History

This retrospective interview tracks alcohol use from onset of regular drinking to current patterns, identifying different drinking phases. 1

Supplementary Biomarkers

Blood tests can supplement but not replace quantitative history-taking. 1

• AST/ALT ratio >2 suggests alcoholic hepatitis (though levels usually <300 IU/L) 1
• Gamma-glutamyltransferase (GGT) elevation 1
• Mean corpuscular volume (MCV) elevation 1
• Carbohydrate-deficient transferrin (CDT) 1
• Combining multiple tests is superior to any single test 1

Direct alcohol metabolite biomarkers include:

• Ethyl glucuronide (EtG) detectable in urine for up to 3 days 1
• Phosphatidylethanol (PEth) for chronic use detection 1

Critical Pitfalls to Avoid

Patients underreport alcohol consumption in 57.7% of cases when compared to objective biomarkers. 2

Obtain drinking history from family members or close contacts when possible, as patients frequently deny or minimize consumption. 1

Restaurant and home pours frequently exceed standard drink definitions—verify actual volumes consumed, not just "number of drinks." 2

Document drinking pattern beyond just quantity: daily drinking carries higher risk (RR = 3.65) than less frequent drinking (RR = 1.34 for <once weekly), and binge drinking (≥5 drinks for men, ≥4 for women in one sitting) significantly increases ALD risk. 3

Record additional risk factors: drinking without meals increases ALD risk 2.7-fold, and mixing drinks, drinking at multiple locations, and younger age of drinking initiation all increase risk. 1, 3