AKT · Gastroenterology/Liver

Alcohol-related liver disease

Spectrum of alcohol-induced liver injury (steatosis → alcoholic hepatitis → cirrhosis)

Overview

A spectrum of liver injury from chronic excess alcohol: fatty liver (steatosis, reversible) → alcoholic hepatitis (acute inflammation, can be severe/fatal) → cirrhosis. Suggested by an AST:ALT ratio >2 and a raised GGT/MCV. Severe alcoholic hepatitis (high discriminant function/MELD) may benefit from corticosteroids. Manage alcohol withdrawal (risk of seizures/delirium tremens) and give thiamine (Wernicke prophylaxis).

Recognise

Spectrum: asymptomatic fatty liver; alcoholic hepatitis (jaundice, tender hepatomegaly, fever, anorexia); decompensated cirrhosis (ascites, encephalopathy, varices)
AST:ALT >2 (classically), raised GGT, raised MCV; signs of chronic liver disease (spider naevi, palmar erythema, Dupuytren, gynaecomastia)
Withdrawal risk on admission: tremor/anxiety → seizures → delirium tremens; Wernicke's (confusion, ophthalmoplegia, ataxia)

Red flags

Severe alcoholic hepatitis (Maddrey discriminant function ≥32) → consider corticosteroids; high mortality
Alcohol withdrawal seizures/delirium tremens; Wernicke encephalopathy → IV thiamine (before glucose)

Differentials & how to tell them apart

MASLD/NAFLDmetabolic (obesity/diabetes) rather than alcohol; ALT often > AST

Viral/autoimmune hepatitisserology/autoantibodies

Other cirrhosis causeshaemochromatosis, Wilson's (see endocrine), PBC/PSC

Investigations

LFTs (AST:ALT >2), GGT, FBC (raised MCV), clotting (INR), albumin; liver USS/fibroscan; exclude other causes (viral, autoimmune, metabolic). Maddrey/MELD for severity.

Management

Alcohol cessation + thiamine + withdrawal management (steroids for severe alcoholic hepatitis)

1Stop alcohol and manage withdrawal (benzodiazepine regimen) with THIAMINE to prevent Wernicke's. Assess severity; nutritional support.Gate: Give THIAMINE before/with any glucose (glucose first can precipitate Wernicke's); severe alcoholic hepatitis (Maddrey ≥32) may warrant corticosteroids — but only after excluding active infection/GI bleeding
2Long-term abstinence support; manage cirrhosis/decompensation (ascites, encephalopathy, varices, HCC surveillance); transplant assessment after a period of abstinence.

Alcohol cessation (the key intervention) + withdrawal management — chlordiazepoxide-assisted withdrawal; THIAMINE (Pabrinex) to prevent Wernicke's

Corticosteroids (severe alcoholic hepatitis) — if Maddrey ≥32, no contraindication (sepsis/GI bleed) — specialist

Nutritional support; manage cirrhosis complications — high-calorie/protein; treat ascites/encephalopathy/varices

Key points

AST:ALT >2 + raised GGT/MCV + alcohol = ALD. Thiamine before glucose (Wernicke's); steroids for severe alcoholic hepatitis. The whole spectrum from reversible steatosis to cirrhosis hinges on abstinence.

Monitor & prognosis

LFTs, abstinence, withdrawal, cirrhosis complications.

Steatosis reversible; severe alcoholic hepatitis/cirrhosis high mortality.

Source: NICE CG100/115; BSG