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Target Audience: Hepatologists, gastroenterologists, primary care clinicians
Now that there is effective treatment for hepatitis C virus (HCV) infection, alcoholic liver disease (ALD) and non-alcoholic fatty liver disease will become the most common liver diseases seen by clinicians. So, it is timely that the ACG has put out a new clinical guideline for the management of alcoholic liver disease. The authors used a standard methodology to evaluate the level of evidence and strength of recommendations.
Counsel men who ingest >3 drinks/day and women who ingest >2 drinks/day that they are at increased risk for ALD.
For initial evaluation of suspected ALD, order liver function tests and abdominal ultrasound.
Do not routinely perform liver biopsy for the diagnosis of ALD.
AH is a clinical diagnosis. Look for worsening jaundice and liver-related complications, documentation of chronic, heavy alcohol use until 8 weeks prior to presentation, and total serum bilirubin >3 mg/dL, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) >1.5 times the upper limit of normal (but <400 U/L), and an AST/ALT ratio >1.5.
In cases of severe AH (defined as a Maddrey's score ≥32 or model for end-stage liver disease [MELD] score >20), hospitalize the patient to prevent kidney injury and undergo a work-up to exclude infections.
If corticosteroids are used to improve 30-day survival, assess the patient's Lille score at day 7, and if >0.45, discontinue therapy.
In highly selected patients who are not responsive to corticosteroid therapy, early liver transplantation can be considered.
Baclofen is effective in preventing alcohol relapse in patients with ALD.
Assess liver transplantation candidacy while managing end-stage ALD.
Do not base transplantation candidacy solely on 6-month alcohol abstinence, consider factors such as social support and need for rehabilitation.
Patients too sick to undergo rehabilitation therapy might be considered for transplantation via exception pathways, depending on the transplant center.
Singal AK et al. ACG clinical guideline: Alcoholic liver disease. Am J Gastroenterol 2018 Jan 16; [e-pub]. (http://dx.doi.org/10.1038/ajg.2017.469)
Comment
This clinical guideline incorporates recently published data regarding alcohol-related liver disease. However, most of the recommendations are based on a low or very low level of evidence. The few recommendations supported by a moderate level of evidence are corticosteroid use in AH to improve short-term survival and early liver transplantation for selected patients with AH. For now, this appears to be a reasonable set of recommendations for clinical use.