What is the management approach for an adult patient with Diffuse Chronic Liver Disease (DCLD) and a history of alcohol abuse or viral hepatitis?

Management of Diffuse Chronic Liver Disease (DCLD)

The management of DCLD in adults with alcohol abuse or viral hepatitis centers on achieving complete alcohol abstinence, treating the underlying liver disease etiology, managing complications of portal hypertension and cirrhosis, and optimizing nutritional status while evaluating for liver transplantation in appropriate candidates. 1

Immediate Priorities: Address the Underlying Etiology

Alcohol-Related Liver Disease Management

• Alcohol abstinence is the single most important intervention and cornerstone of therapy for all patients with alcohol-related liver disease. 1 Patients with Child-Pugh C cirrhosis who achieve abstinence have approximately 75% 3-year survival, while those who continue drinking have 100% mortality at 3 years. 1

• Refer all patients with AUDIT score ≥19 to specialized alcohol services for management of alcohol dependency. 1

• For patients without advanced liver disease, acamprosate is the only medication with sufficient high-quality evidence demonstrating superiority over placebo for maintaining alcohol abstinence. 2, 3 Dosing is 1,998 mg/day for patients ≥60 kg (reduced by one-third for <60 kg), initiated 3-7 days after last alcohol consumption, for 3-6 months. 1

• For patients with advanced liver disease or decompensated cirrhosis, baclofen is recommended instead of naltrexone or acamprosate, as it is safe and effective for preventing alcohol relapse without hepatotoxicity risk. 2, 3

• Critical pitfall: Never use naltrexone in patients with alcoholic liver disease due to significant hepatotoxicity risk. 2, 3

• Implement brief motivational interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) delivered in 5-30 minutes. 2, 3, 4

• Actively encourage engagement with Alcoholics Anonymous as it is highly effective and should be routinely recommended. 2, 3

Viral Hepatitis Management

• In patients with abnormal liver function, investigate for acute and chronic viral hepatitis (HBV, HCV) according to clinical presentation and local epidemiology. 1

• Specific antiviral treatment of underlying chronic viral hepatitis can improve liver tests and potentially reverse disease progression. 1

• When using corticosteroids for any indication in patients with chronic HBV, monitor closely for HBV reactivation risk. 1

Risk Stratification and Fibrosis Assessment

• All patients with harmful alcohol use should undergo risk stratification with clinical assessment and FibroScan/ARFI elastography. 1

• Refer to hepatology if FibroScan reading is >16 kPa, or if there are features of cirrhosis or portal hypertension on imaging or blood tests. 1

• For patients with NAFLD component or unclear etiology, calculate FIB-4 or NAFLD fibrosis score initially. 1 Values <1.3 (FIB-4) or ≤1.455 (NAFLD fibrosis score) indicate low risk of advanced fibrosis. For patients >65 years, use higher cut-offs (<2.0 and <0.12 respectively). 1

• Bedside ultrasonography should be performed to evaluate for cirrhosis, hepatocellular carcinoma, and biliary pathology. 1

Management of Cirrhosis Complications

Ascites Management

• Implement dietary sodium restriction to 2000 mg per day (88 mmol per day) as the mainstay of treatment. 1 Fluid loss and weight change are directly related to sodium balance in portal hypertension-related ascites. 1

• Initiate oral diuretics in combination with sodium restriction. 1 The standard approach uses spironolactone with or without furosemide.

• Fluid restriction is not necessary in most patients with cirrhotic ascites. 1 Chronic hyponatremia in this setting is seldom morbid, and attempts at rapid correction with hypertonic saline can cause more complications than the hyponatremia itself. 1

• Avoid diuretics and nephrotoxic drugs in patients at risk for acute kidney injury, particularly those with severe alcoholic hepatitis. 1

• Perform diagnostic paracentesis with ascitic fluid cell count and differential, total protein, and serum-ascites albumin gradient (SAAG) in all new-onset ascites. 1

• If ascitic fluid infection is suspected, culture ascitic fluid at bedside in blood culture bottles. 1

Portal Hypertension and Variceal Management

• Screen for and manage portal hypertension complications including variceal bleeding. 1

• Consider avoiding beta-blockers in severe alcoholic hepatitis as they may increase risk of acute kidney injury. 1

Hepatic Encephalopathy

• Treat hepatic encephalopathy with lactulose and rifaximin as indicated. 1

• Rule out other causes of encephalopathy and identify/treat precipitating factors before initiating empiric treatment. 5

Nutritional Management

• Malnutrition is present in almost every patient with severe alcoholic hepatitis and is associated with poor prognosis. 1

• Target daily energy intake of 35-40 kcal/kg body weight and daily protein intake of 1.2-1.5 g/kg body weight. 1

• Patients with daily calorie intake below 21.5 kcal/kg body weight have significantly worse outcomes regardless of other therapies. 1

• Strongly consider tube feeding if patients cannot maintain adequate oral intake to meet nutritional goals. 1

• Supplement with B-complex vitamins to prevent Wernicke's encephalopathy. 1

• Provide supplemental fat-soluble and water-soluble vitamins, minerals, and trace elements. 5

Severe Alcoholic Hepatitis Specific Management

• Calculate modified Maddrey discriminant function (mDF); a value ≥32 identifies severe alcoholic hepatitis requiring specific therapy. 1

• Alternative prognostic scores include MELD (score >20 indicates high risk of 90-day mortality), Glasgow alcoholic hepatitis score (GAHS ≥9 indicates poor prognosis), and ABIC score. 1

• Avoid nephrotoxic drugs and provide volume expansion if needed to prevent acute kidney injury. 1

• Implement measures for salt restriction in ascites management. 1

Liver Transplantation Evaluation

• Refer appropriate candidates for liver transplantation evaluation early in the disease course. 6 It is often not appropriate to exhaust all treatment options before referring for transplantation. 6

• The increasing availability and success of liver transplantation has changed the emphasis of management toward earlier referral. 6

Monitoring and Follow-up

• Ensure regular follow-up appointments every 1-3 months to assess progress, medication adherence, and continued abstinence. 3

• Screen for hepatocellular carcinoma in cirrhotic patients according to standard surveillance protocols. 1

• Monitor for development of acute-on-chronic liver failure (ACLF), which carries high short-term mortality and may require intensive care management. 7, 8

• Most patients with ACLF will have clear prognosis between day 3-7 of hospital admission, allowing for clinical decisions regarding liver transplant evaluation or goals of care discussions. 7

Psychosocial Support

• Implement cognitive behavioral therapy to help patients develop coping skills and address psychological patterns underlying drinking behavior. 3

• Involve family members in treatment and encourage participation in family support groups. 4

• Continue psychosocial treatment after discharge to prevent recurrence, as relapse rates can reach 50% at one year. 3