Alcohol-Related Liver Disease (ARLD)

ARLD is a spectrum of liver pathology resulting from chronic and excessive alcohol consumption, encompassing: ^[Ref]

• Alcoholic fatty liver (isolated steatosis) – reversible
• Alcoholic hepatitis (steatohepatitis) – potentially reversible
• Alcoholic cirrhosis – irreversible

ARLD mainly results from 2 pathophysiological mechanisms ^[Ref]

• Steatosis (fatty liver)
  • Alcohol metabolism increases NADH:NAD⁺ ratio → inhibits lipolysis and stimulates lipogenesis → triglycerides accumulate in hepatocytes
• Hepatitis
  • Alcohol is metabolised to acetaldehyde (a toxic metabolite) → acetaldehyde causes oxidative stress and direct hepatocyte injury → activates Kupffer cells → release of inflammatory cytokines

Chronic inflammation in the liver activates stellate cells → fibrosis → irreversible cirrhosis

Features that are more suggestive of ARLD (as opposed to general chronic liver disease):

• History of heavy alcohol use – one of the most important factors
• Parotid gland enlargement (alcoholic sialadenosis)
• Dupuytren’s contracture
• Temporal muscle wasting
• Peripheral neuropathy (due to vitamin B deficiency)
• Sarcopenia (muscle wasting but relatively preserved fat) (due to protein-calorie malnutrition)

Most other clinical features are non-specific and can be seen in any cause of chronic liver disease:

Biochemical changes in ARLD: ^[Ref]

• ↑ AST and ALT (but <400 IU/L – i.e. not markedly raised)
  • AST:ALT ratio >2
  • But AST and ALT levels should NOT be markedly raised (< 400 IU/L) (higher than 400 IU/L should raise concern of other causes)
• ↑ GGT
• Macrocytosis / macrocytic anaemia

Biochemical changes due to impaired liver synthetic function: ^[Ref]

• ↑ Bilirubin
• ↑ PT / INR
• ↓ Albumin
• ↓ Platelet

Choice of imaging:

• 1st line: ultrasound
• 2nd line: CT

Definitive test: transjugular liver biopsy

• It is NOT performed routinely, only reserved for cases when diagnosis is uncertain / atypical presentation / atypical laboratory tests / high suspicion of autoimmune hepatitis
• Liver biopsy is associated with a significant risk of morbidity and mortality

NICE recommends using transient elastographyTransient elastrography measures liver stiffness in kPa. Increased liver stiffness suggests cirrhosis. (e.g. FibroScan) to check for cirrhosis in patients with ARLD

See the Cirrhosis article for further information.

There is no specific treatment for ARLD, apart from providing general / conservative advice and care:

• Alcohol abstinence (see the Alcohol Use Disorders article) – most important
• Offer oral thiamine (as patients with ARLD are often thiamine-deficient and at risk of Wernicke’s encephalopathy)
• Offer hepatitis A and B immunisations (to be offered to those with chronic liver disease)

• Assess nutritional intake and offer support if needed
• Lifestyle advice (e.g. weight reduction, smoking cessation)
• Optimise other comorbidities (e.g. obesity, diabetes, hypertension)

Apart from supportive care, corticosteroids can be offered to those with severe alcoholic hepatitis (defined as discriminant functionTakes the following into account: - Prothrombin time - Bilirubin level ≥32)