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Alcoholic liver disease 

Alcoholic liver disease

Alcoholic liver disease

Stephen F. Stewart

and Chris P. Day



Treatment for alcoholic hepatitis updated to reflect negative trials of etanercept and MARS and positive trials of N-acetylcysteine and early transplantation.

Recommendations on pharmacotherapy updated to include nalmefene.

Updated on 28 Nov 2012. The previous version of this content can be found here.
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date: 30 March 2017

The incidence of alcoholic liver disease (ALD) follows the trend of per capita alcohol consumption, with hepatic injury which extends from fatty liver to alcoholic hepatitis and cirrhosis. It is unclear how alcohol causes liver disease, but postulated mechanisms include (1) oxidative stress and acetaldehyde generated by the metabolism of ethanol, and (2) innate and adaptive immune responses. Factors determining the susceptibility to liver disease in heavy drinkers are believed to include a variety of host and environmental factors.

Clinical manifestations are extremely variable, and some patients remain while others suffer the effects of severe hepatic failure. Although patients can come to light with a life-threatening complication, most often they develop symptoms which are not immediately related to the liver, such as nonspecific digestive symptoms or psychiatric complaints. The key to the early recognition of alcohol-related disease is having a high index of suspicion, with confirmation by (1) direct questioning for alcohol history and alcohol-related symptoms; (2) clinical examination for signs of chronic liver disease; (3) supportive investigations, including elevation of serum γ‎-glutamyl transferase (γ‎GT) and aspartate transaminase (AST); and (4) liver biopsy, which is often required for accurate prognostication, revealing alcoholic fatty liver, alcoholic hepatitis, or cirrhosis.

Management is governed by the stage and severity of the liver disease, but always includes abstinence and adequate nutritional support. In selected patients with severe acute alcoholic hepatitis, corticosteroids and pentoxifylline can reduce mortality. For alcoholic cirrhosis, transplantation remains the only effective treatment, although mainly as a result of concerns about post-transplant recidivism, this remains controversial.

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