Alcoholic Liver Disease

Abstract

This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and the American College of Gastroenterology and represents the position of both associations. These recommendations provide a data-supported approach. They are based on the following: (1) formal review and analysis of the recently published world literature on the topic (Medline search); (2) American College of Physicians Manual for Assessing Health Practices and Designing Practice Guidelines1; (3) guideline policies, including the AASLD Policy on the development and use of Practice Guidelines and the American Gastroenterological Association Policy Statement on Guidelines2; and (4) the experience of the authors in the specified topic. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting recommendations, the Practice Guideline Committee of the AASLD requires a Class (reflecting benefit versus risk) and Level (assessing strength or certainty) of Evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart Association Practice Guidelines).3, 4 AASLD, American Association for the Study of Liver Diseases; AH, alcoholic hepatitis; ALD, alcoholic liver disease; ALT, alanine aminotransferase; AST, aspartate aminotransferase; AUDIT, Alcohol Use Disorders Identification Test; GAHS, Glasgow Alcoholic Hepatitis Score; GGT, gamma glutamyl transpeptidase; MDF, Maddrey discriminant function; MELD, Model for End-Stage Liver Disease; MRI, magnetic resonance imaging; PTU, propylthiouracil; SAMe, S-adenosyl L-methionine; TNF, tumor necrosis factor. Alcoholic liver disease (ALD) encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis. It may well represent the oldest form of liver injury known to humankind. Evidence suggests that fermented beverages existed at least as early as the Neolithic period (circa 10,000 B.C.),5 and liver disease related to it almost as long. Alcohol remains a major cause of liver disease worldwide. It is common for patients with ALD to share risk factors for simultaneous injury from other liver insults (e.g., coexisting nonalcoholic fatty liver disease, or chronic viral hepatitis). Many of the natural history studies of ALD, and even treatment trials, were performed before these other liver diseases were recognized, or specific testing was possible. Thus, the individual effect of alcohol in some of these studies may have been confounded by the presence of these additional injuries. Despite this limitation, the data regarding ALD are robust enough to draw conclusions about the pathophysiology of this disease. Possible factors that affect the development of liver injury include the dose, duration, and type of alcohol consumption; drinking patterns; sex; ethnicity; and associated risk factors including obesity, iron overload, concomitant infection with viral hepatitis, and genetic factors. Geographic variability exists in the patterns of alcohol intake throughout the world.6 Approximately two-thirds of adult Americans drink some alcohol.7 The majority drink small or moderate amounts and do so without evidence of clinical disease.8-10 A subgroup of drinkers, however, drink excessively, develop physical tolerance and withdrawal, and are diagnosed with alcohol dependence.11 A second subset, alcohol abusers and problem drinkers, are those who engage in harmful use of alcohol, defined by the development of negative social and health consequences of drinking (e.g., unemployment, loss of family, organ damage, accidental injury, or death).12 Failure to recognize alcoholism remains a significant problem and impairs efforts at both the prevention and management of patients with ALD.13, 14 Although the exact prevalence is unknown, approximately 7.4% of adult Americans were estimated to meet DSM-IV criteria for the diagnosis of alcohol abuse and/or alcohol dependence in 199415; more recent data suggest 4.65% meet criteria for alcohol abuse and 3.81% for alcohol dependence.16 In 2003, 44% of all deaths from liver disease were attributed to alcohol.17 Population level mortality from alcoholic liver disease is related to per capita alcohol consumption obtained from national alcoholic beverage sales data. There are conflicting data regarding a possible lower risk of liver injury in wine drinkers.18, 19 One epidemiologic study has estimated that for every 1-liter increase in per capita alcohol consumption (independent of type of beverage), there was a 14% increase in cirrhosis in men and 8% increase in women.20 These data must be considered in the context of the limi