This is the current release of the guideline.

Alcoholic liver disease including:

• Fatty liver or simple steatosis
• Alcoholic hepatitis
• Chronic hepatitis with hepatic fibrosis or cirrhosis

To provide data-supported recommendations for the diagnosis and treatment of alcoholic liver disease

Patients with alcoholic liver disease

Diagnosis/Evaluation/Screening

1. Discussing alcohol use with patients
2. Screening for alcohol abuse using structured questionnaires (e.g., CAGE, Alcohol Use Disorders Identification Test [AUDIT])
3. Physical examination
4. Laboratory tests including serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels
5. Hepatic imaging
6. Screening for evidence of other end-organ damage, as appropriate
7. Liver biopsy, if indicated 
8. Identifying patients at highest risk of poor outcome using the Maddrey Discriminant Function (MDF) or Model for End-Stage Liver Disease (MELD) scoring systems

Management/Treatment

1. Abstinence
2. Naltrexone or acamprosate in combination with counseling
3. Nutrition therapy
4. Steroids (prednisolone)
5. Pentoxifylline
6. Close monitoring of patients with mild-to-moderate disease
7. Long-term management including frequent feeding, night time snacks, micronutrient and vitamin replacement; consideration of clinical trial participation; management of complications
8. Liver transplantation

A formal review and analysis of the recently published world literature on the topic, including a Medline search, was performed.

Not stated

Levels of Evidence

Level A Data derived from multiple randomized clinical trials or meta-analyses

Level B Data derived from a single randomized trial, or nonrandomized studies

Level C Only consensus opinion of experts, case studies, or standard-of-care

Not stated

Not stated

Grading System for Recommendations

Class I Conditions for which there is evidence and/or general agreement that a given diagnostic evaluation, procedure or treatment is beneficial, useful, and effective

Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a diagnostic evaluation, procedure or treatment

Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy

Class IIb Usefulness efficacy is less well established by evidence/opinion

Class III Conditions for which there is evidence and/or general agreement that a diagnostic evaluation/procedure/treatment is not useful/effective and in some cases may be harmful

A formal cost analysis was not performed and cost analyses were not reviewed.

The Practice Guidelines Committee of the American Association for the Study of Liver Diseases (AASLD) and the Practice Parameters Committee of the American College of Gastroenterology provided extensive peer review of the manuscript.

This guideline has been approved by the AASLD and the American College of Gastroenterology and represents the position of both associations.

The grading system for the class of recommendations (I, II, IIa, IIb, III) and the levels of evidence (A–C) is defined at the end of the "Major Recommendations" field.

Diagnosis

1. Clinicians should discuss alcohol use with patients, and any suspicion of possible abuse or excess should prompt use of a structured questionnaire and further evaluation (Class I, level C).
2. For patients with a history of alcohol abuse or excess and evidence of liver disease, further laboratory tests should be done to exclude other etiologies and to confirm the diagnosis (Class I, level C).
3. Patients with alcoholic liver disease (ALD) and suggestive symptoms should be screened for evidence of other end-organ damage, as appropriate (Class I, level C).
4. For patients with a clinical diagnosis of severe alcoholic hepatitis (AH) for whom medical treatment is contemplated, or for those in whom reasonable uncertainty exists regarding the underlying diagnosis, a liver biopsy should be considered. This decision will depend on local expertise and ability in performing a liver biopsy in patients with coagulopathy, the patient’s severity of illness, and the type of therapy under consideration (Class I, level C).

Prognostic Factors

5. Patients presenting with a high clinical suspicion of alcoholic hepatitis should have their risk for poor outcome stratified using the Maddrey Discriminant Function (MDF), as well as other available clinical data. Evaluating a patient's condition over time with serial calculation of the Model for End-Stage Liver Disease (MELD) score is also justified (Class I, level B).

Therapy

Abstinence

6. In patients with evidence of alcohol-induced liver disease, strict abstinence must be recommended, because continued alcohol use is associated with disease progression (Class I, level B).
7. Naltrexone or acamprosate may be considered in combination with counseling to decrease the likelihood of relapse in patients with alcohol abuse/dependence in those who achieve abstinence (Class I, level A).

Therapy for Alcoholic Hepatitis

8. All patients with alcoholic hepatitis should be counseled to completely abstain from alcohol (Class I, level B).
9. All patients with alcoholic hepatitis or advanced ALD should be assessed for nutritional deficiencies (protein-calorie malnutrition), as well as vitamin and mineral deficiencies. Those with severe disease should be treated aggressively with enteral nutritional therapy (Class I, level B).
10. Patients with mild-moderate alcoholic hepatitis—defined as a Maddrey score of <32, without hepatic encephalopathy, and with improvement in serum bilirubin or decline in the MDF during the first week of hospitalization—should be monitored closely, but will likely not require nor benefit from specific medical interventions other than nutritional support and abstinence (Class III, level A).
11. Patients with severe disease (MDF score of >32, with or without hepatic encephalopathy) and lacking contraindications to steroid use should be considered for a four week course of prednisolone (40 mg/day for 28 days, typically followed by discontinuation or a 2-week taper) (Class I, level A).
12. Patients with severe disease (i.e., a MDF >32) could be considered for pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks), especially if there are contraindications to steroid therapy (Class I, level B).

Long-Term Management of ALD

13. Patients with alcoholic cirrhosis should receive frequent interval feedings, emphasizing a night time snack and morning feeding, to improve nitrogen balance (Class I, level A).
14. Propylthiouracil (PTU) and colchicine should not be used in the treatment of patients with ALD; S-adenosyl L-methionine (SAMe) should be used only in clinical trials (Class III, level A)
15. The use of complementary or alternative medicines in the treatment of either acute or chronic alcohol-related liver disease has shown no convincing benefit and should not be used out of the context of clinical trial (Class III, level A).

Liver Transplantation for ALD

16. Appropriate patients with end-stage liver disease secondary to alcoholic cirrhosis should be considered for liver transplantation, just as other patients with decompensated liver disease, after careful evaluation of medical and psychosocial candidacy. In addition, this evaluation should include a formal assessment of the likelihood of long-term abstinence (Class I, Level B).

Definitions:

Levels of Evidence

Level A Data derived from multiple randomized clinical trials or meta-analyses

Level B Data derived from a single randomized trial, or nonrandomized studies

Level C Only consensus opinion of experts, case studies, or standard-of-care

Grading System for Recommendations

Class I Conditions for which there is evidence and/or general agreement that a given diagnostic evaluation, procedure or treatment is beneficial, useful, and effective

Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a diagnostic evaluation, procedure or treatment

Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy

Class IIb Usefulness efficacy is less well established by evidence/opinion

Class III Conditions for which there is evidence and/or general agreement that a diagnostic evaluation/procedure/treatment is not useful/effective and in some cases may be harmful

Clinical algorithms are provided in the original guideline document for:

• Management of alcoholic hepatitis
• Long-term management of alcoholic liver disease (ALD)

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Appropriate diagnosis and treatment of alcoholic liver disease

Naltrexone has been shown to cause hepatocellular injury.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American Association for the Study of Liver Diseases

Practice Guidelines Committee

Primary Authors: Robert S. O'Shea, Srinivasan Dasarathy, Arthur J. McCullough

Committee Members: Margaret C. Shuhart, M.D., M.S., (Committee Chair); Gary L. Davis, M.D. (Board Liaison); Jose Franco, M.D.; Stephen A. Harrison, M.D.; Charles D. Howell, M.D.; Simon C. Ling, MBChB, MRCP; Lawrence U. Liu, M.D.; Paul Martin, M.D.; Nancy Reau, M.D.; Bruce A. Runyon, M.D.; Jayant A. Talwalkar, M.D., MPH; John B.  Wong, M.D.; and Colina Yim, RN, MN

Potential conflict of interest: none of the authors received financial support/editorial assistance to support the research and the preparation of the article for submission.

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF) from the American Association for the Study of Liver Diseases Web site .

Print copies: Available from the American Association for the Study of Liver Diseases, 1729 King Street, Suite 200; Alexandria, VA 22314; Phone: 703-299-9766; Web site: www.aasld.org ; e-mail: aasld@aasld.org.

This guideline is available as a Personal Digital Assistant (PDA) download via the APPRISOR™ Document Viewer from www.apprisor.com .

None available

This NGC summary was completed by ECRI Institute on February 28, 2010. The information was verified by the guideline developer on March 24, 2010.

This NGC summary is based on the original guideline, which is subject to the American Association for the Study of Liver Diseases' copyright restrictions.