What is the recommended workup and management for a patient suspected of having alcoholic liver disease?

Workup for Alcoholic Liver Disease

Initial Clinical Assessment

Begin by documenting alcohol consumption history with specific thresholds: >40g/day in men and >20-30g/day in women for at least 6 months establishes risk for alcoholic liver disease. 1, 2

Alcohol Use Screening

• Use the AUDIT questionnaire as first-line screening: scores ≥8 for men under 60 or ≥4 for women, adolescents, or men over 60 are positive 2
• The CAGE questionnaire is an acceptable alternative due to its simplicity 2
• Quantify both total daily intake and drinking patterns over the preceding 2 years 2
• Confirm self-reported consumption with family members if clinical suspicion is high 1

Physical Examination Findings

• Assess for bilateral parotid gland hypertrophy, muscle wasting, malnutrition, Dupuytren's contracture, and symmetric peripheral neuropathy 2
• Look for tender hepatomegaly, jaundice, ascites, and signs of portal hypertension 1, 3
• Evaluate for hepatosplenomegaly and signs of decompensation 4

Laboratory Evaluation

Initial Blood Tests

• AST/ALT ratio >2 is highly suggestive of alcoholic liver disease, with ratios >3 being even more specific 2
• AST is typically elevated 2-6 times the upper limit of normal, but AST >500 IU/L or ALT >200 IU/L suggest alternative etiologies 2
• Measure serum bilirubin, INR/prothrombin time, albumin, and complete blood count with platelets to assess liver synthetic function and portal hypertension 1
• Elevated GGT combined with elevated MCV (mean corpuscular volume) improves sensitivity for chronic alcohol use 2
• Thrombocytopenia may indicate advanced disease 2

Exclusion of Other Liver Diseases

• Test for hepatitis B surface antigen, hepatitis C antibody, and HIV to exclude viral hepatitis 1, 2
• Consider testing for hemochromatosis (iron studies, HFE gene), alpha-1 antitrypsin deficiency, Wilson disease, and autoimmune hepatitis markers based on clinical context 1
• Approximately 20% of patients with alcohol use disorder and abnormal liver tests have coexisting liver disease 1, 2

Direct Alcohol Biomarkers (Optional)

• Ethyl glucuronide (EtG) in urine detects alcohol use for 3-4 days 2
• Hair EtG can detect chronic excessive consumption with cut-offs: <7 pg/mg (abstinence), 7-30 pg/mg (social drinking), >30 pg/mg (chronic excessive use) 2

Non-Invasive Fibrosis Assessment

Perform FibroScan (transient elastography) or specialized blood tests (FibroTest or FibroMeter Alcohol) as first-line evaluation for fibrosis staging in all patients with suspected alcoholic liver disease. 2

Important Caveats for Liver Stiffness Measurement

• Interpret elevated liver stiffness cautiously when AST >100 U/L, as superimposed alcoholic hepatitis may falsely elevate values 1
• Liver stiffness decreases with abstinence and increases with relapse 1
• These methods detect advanced fibrosis/cirrhosis with approximately 95% accuracy 2
• Do not use APRI score for fibrosis assessment in alcoholic liver disease 2

Imaging Studies

Abdominal Ultrasound

• Perform ultrasound to screen for steatosis (though sensitivity is low when steatosis <20-30%) 1
• Assess for signs of cirrhosis: liver dysmorphy, portal-systemic collaterals, splenomegaly 1
• Evaluate for ascites and hepatocellular carcinoma 1

Upper Endoscopy

• Perform upper gastrointestinal endoscopy when cirrhosis is evident to screen for esophageal varices, unless low-risk criteria are met (platelets >150,000 and FibroScan <20) 1

Liver Biopsy Indications

Reserve liver biopsy for specific scenarios rather than routine use, as it carries 2% risk of severe complications including bleeding and pneumothorax. 1

When to Consider Liver Biopsy

• Suspected alcoholic hepatitis requiring specific treatment (corticosteroids) for definitive diagnosis and prognosis 1, 2, 4
• Discordant or inconclusive non-invasive test results 1, 2
• Suspected coexisting chronic liver disease (present in 20-30% of cases) 1, 4
• Atypical presentation with confounding factors 2, 4
• Clinical trial participation 1

Biopsy Technique

• Use transjugular approach in patients with coagulopathy (INR >1.2-1.3), thrombocytopenia (<150,000/μL), or ascites 1, 2, 3
• Percutaneous biopsy under ultrasound guidance is acceptable when coagulation parameters are normal 1

Histologic Features to Assess

• Macrovesicular steatosis (may be mixed with microvesicular) 1, 4
• Hepatocyte ballooning and necrosis 1, 4
• Neutrophil infiltration (polymorphonuclear cells) 1, 4
• Mallory-Denk bodies 1, 4
• Fibrosis pattern (perisinusoidal "chicken-wire" fibrosis, perivenular fibrosis) 1
• Cholestasis (canalicular and ductular) - important prognostic marker 1
• Megamitochondria 1

Severity Assessment for Alcoholic Hepatitis

When Alcoholic Hepatitis is Suspected (Jaundice + Recent Heavy Drinking)

• Calculate Maddrey Discriminant Function: score ≥32 defines severe alcoholic hepatitis requiring treatment consideration 3, 4
• Calculate MELD score: >20-21 indicates severe disease with high 90-day mortality 3, 4
• Assess for fever, leukocytosis, and tender hepatomegaly 3
• Bilirubin >3 mg/dL with AST >50 IU/mL and AST/ALT ratio >1.5 are characteristic 3

Diagnostic Classification of Alcoholic Hepatitis

• Definite: Clinical diagnosis plus biopsy confirmation 3
• Probable: Clinical diagnosis with typical presentation without confounding factors 3
• Possible: Clinical diagnosis with atypical features 3

Critical Pitfalls to Avoid

• Normal liver tests do not exclude significant alcoholic liver disease 2
• Only 70-80% of clinically suspected severe alcoholic hepatitis cases are confirmed on biopsy 4
• AST/ALT ratio becomes less specific in cirrhotic stage 2
• GGT loses specificity for alcohol in advanced liver disease 2
• Even "moderate" alcoholic hepatitis (Maddrey <32) carries 10% mortality at 6 months and 20% at 1 year 3

Additional Assessments

• Screen for cognitive impairment, metabolic syndrome, and smoking status as these impact disease progression 2
• Evaluate for alcohol withdrawal syndrome risk in hospitalized patients 5
• Assess nutritional status and initiate supplementation early 4, 5