management of alcoholic liver disease

FREE subscriptions for doctors and students... click here
You have 3 more open access pages.

General measures common to the management of all patients with ALD are:

  • encourage immediate and total abstinence from alcohol
  • anticipate the development of withdrawal - see the section on alcoholic withdrawal

Alcoholic steatosis is usually reversible with abstinence. The patient may later be allowed to return to modest drinking provided that this can be controlled and that they are fully informed of the problems of further drinking.

Alcoholic hepatitis:

  • treatment for ascites and encephalopathy should be commenced in patients with acute alcoholic hepatitis. Treatment with pentoxifylline or corticosteroids may help increase survival in patients with acute severe alcoholic hepatitis, at least in the short term (1). In the management of alcoholic hepatitis, corticosteroid therapy may be employed on a pragmatic basis for 1 week and discontinued if no response (1)
    • NICE suggest the use Maddrey's discriminant function (DF) to determine treatment in people with severe acute alcohol related hepatitis (2)
    • DF of 32 or more
      • consider liver biopsy to confirm diagnosis
      • offer corticosteroid treatment
  • if hepatorenal syndrome develops, fluids, antibacterial therapy and terlipressin may help - however prognosis is poor
  • potassium, zinc and magnesium supplements are usually given as stores are low. Vitamins, especially, B complex, C and K are advised. Nitrogen balance must be maintained. Natural protein taken orally is adequate for most patients. Amino acid supplementation, orally or intravenously, should be reserved for the most jaundiced and malnourished patients
  • long-term survival following alcoholic hepatitis depends on lifelong abstinence from alcohol: psychological support and acamprosate may help ensure this (1)

In people with delirium tremens, offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol (2)

Cirrhosis is irreversible, and treatment is directed at its complications. Liver transplantation may be required

  • NICE suggest that patients should be referred for consideration of liver transplantation if they have decompensated liver disease and:

    • still have decompensated liver disease after best management and 3 months' abstinence from alcohol and
    • are otherwise suitable candidates for liver transplantation

Notes:

  • Maddrey's discriminant function (DF) was described to predict prognosis in alcohol-related hepatitis and identify patients suitable for treatment with steroids
    • it is 4.6 x [prothrombin time - control time (seconds)] + bilirubin in mg/dl.
      • to calculate the DF using bilirubin in micromol/l divide bilirubin value by 17

  • steroid treatment in severe alcohol-related hepatitis and a discriminant function of 32 or more,
    • steroid treatment is indicated only after:
      • effectively treating any active infection or gastrointestinal bleeding that may be present
      • controlling any renal impairment
      • discussing the potential benefits and risks with the person and their family members or carers (as appropriate), explaining that corticosteroid treatment:
        • has been shown to improve survival in the short term (1 month)
        • has not been shown to improve survival over a longer term (3 months to 1 year)
        • has been shown to increase the risk of serious infections within the first 3months of starting treatment

  • NICE suggest that parenteral thiamine should be offered to people with suspected Wernicke’s encephalopathy. Maintain a high level of suspicion for the possibility of Wernicke’s encephalopathy, particularly if the person is intoxicated. Parenteral thiamine should be given for a minimum of 5 days, unless Wernicke’s encephalopathy is excluded. Oral thiamine should follow parenteral therapy

Reference:

Last reviewed 01/2018

Links: