Prognosis and management of alcoholic fatty liver disease and alcoholic cirrhosis
- Scott L Friedman, MD
Scott L Friedman, MD
- Fishberg Professor of Medicine
- Icahn School of Medicine at Mount Sinai
- Section Editors
- Keith D Lindor, MD
Keith D Lindor, MD
- Section Editor — Alcoholic and Metabolic Liver Disease
- Professor of Medicine, Mayo Clinic College of Medicine
- Dean, College of Health Solutions
- Arizona State University
- Timothy O Lipman, MD
Timothy O Lipman, MD
- Section Editor — Nutrition
- GI-Hepatology-Nutrition Section
- Washington DC Veterans Affairs Medical Center
Excessive alcohol consumption is associated with a range of hepatic manifestations, including alcoholic fatty liver disease (with or without steatohepatitis), acute alcoholic hepatitis, and cirrhosis. Patients with an alcohol intake of 30 or more grams per day (one standard drink contains 14 grams of alcohol (figure 1)) are at increased risk of cirrhosis, although the majority of patients will not develop cirrhosis despite heavy alcohol intake (point prevalence of 1 percent for those who drink 30 to 60 g/day and 6 percent for those who drink 120 g/day) [1,2].
There are few specific therapies available for patients with alcoholic liver disease. There is, however, one extremely important intervention, abstinence, since continued alcohol ingestion is the single most important risk factor for progression of the disease . Abstinence is also critical for those patients with cirrhosis to decrease the risk of complications. In addition, patients must be abstinent in order to be listed for liver transplantation. Referral to an alcohol rehabilitation program is usually necessary in combination with family support and counseling. (See "Liver transplantation in alcoholic liver disease" and "Psychosocial treatment of alcohol use disorder" and "Pharmacotherapy for alcohol use disorder".)
This topic will review the prognosis and general management of alcoholic fatty liver disease and alcoholic cirrhosis. The clinical manifestations and diagnosis of alcoholic liver disease, the management of the complications of cirrhosis, the pathogenesis of alcoholic liver disease, and the approach to patients with acute alcoholic hepatitis are discussed separately. (See "Clinical manifestations and diagnosis of alcoholic fatty liver disease and alcoholic cirrhosis" and "Cirrhosis in adults: Overview of complications, general management, and prognosis" and "Pathogenesis of alcoholic liver disease" and "Alcoholic hepatitis: Clinical manifestations and diagnosis" and "Management and prognosis of alcoholic hepatitis" and "Liver transplantation in alcoholic liver disease".)
In 2010, the American Association for the Study of Liver Diseases and the American College of Gastroenterology issued a joint guideline for the management of patients with alcoholic liver disease . Another guideline was published in 2012 by the European Association for the Study of the Liver . The discussion that follows is generally consistent with these guidelines.
NATURAL HISTORY AND PROGNOSTIC FACTORS
Alcohol abuse may lead to steatosis, steatohepatitis, cirrhosis, and hepatocellular carcinoma. Not all patients who drink heavily develop alcoholic liver disease. However, once alcoholic liver disease develops, continued alcohol use typically leads to persistent and often progressive liver disease [6,7]. (See "Clinical manifestations and diagnosis of alcoholic fatty liver disease and alcoholic cirrhosis", section on 'Natural history'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bellentani S, Saccoccio G, Costa G, et al. Drinking habits as cofactors of risk for alcohol induced liver damage. The Dionysos Study Group. Gut 1997; 41:845.
- Lucey MR, Mathurin P, Morgan TR. Alcoholic hepatitis. N Engl J Med 2009; 360:2758.
- Chedid A, Mendenhall CL, Gartside P, et al. Prognostic factors in alcoholic liver disease. VA Cooperative Study Group. Am J Gastroenterol 1991; 86:210.
- O'Shea RS, Dasarathy S, McCullough AJ, et al. Alcoholic liver disease. Hepatology 2010; 51:307.
- European Association for the Study of Liver. EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012; 57:399.
- Parés A, Caballería J, Bruguera M, et al. Histological course of alcoholic hepatitis. Influence of abstinence, sex and extent of hepatic damage. J Hepatol 1986; 2:33.
- Borowsky SA, Strome S, Lott E. Continued heavy drinking and survival in alcoholic cirrhotics. Gastroenterology 1981; 80:1405.
- Gao B, Bataller R. Alcoholic liver disease: pathogenesis and new therapeutic targets. Gastroenterology 2011; 141:1572.
- Saunders JB, Davis M, Williams R. Do women develop alcoholic liver disease more readily than men? Br Med J (Clin Res Ed) 1981; 282:1140.
- Barrio E, Tomé S, Rodríguez I, et al. Liver disease in heavy drinkers with and without alcohol withdrawal syndrome. Alcohol Clin Exp Res 2004; 28:131.
- Hatton J, Burton A, Nash H, et al. Drinking patterns, dependency and life-time drinking history in alcohol-related liver disease. Addiction 2009; 104:587.
- Poynard T, Mathurin P, Lai CL, et al. A comparison of fibrosis progression in chronic liver diseases. J Hepatol 2003; 38:257.
- Raynard B, Balian A, Fallik D, et al. Risk factors of fibrosis in alcohol-induced liver disease. Hepatology 2002; 35:635.
- Pessione F, Ramond MJ, Peters L, et al. Five-year survival predictive factors in patients with excessive alcohol intake and cirrhosis. Effect of alcoholic hepatitis, smoking and abstinence. Liver Int 2003; 23:45.
- Jepsen P, Ott P, Andersen PK, et al. Clinical course of alcoholic liver cirrhosis: a Danish population-based cohort study. Hepatology 2010; 51:1675.
- Orrego H, Israel Y, Blake JE, Medline A. Assessment of prognostic factors in alcoholic liver disease: toward a global quantitative expression of severity. Hepatology 1983; 3:896.
- Alvarez MA, Cirera I, Solà R, et al. Long-term clinical course of decompensated alcoholic cirrhosis: a prospective study of 165 patients. J Clin Gastroenterol 2011; 45:906.
- Orrego H, Blake JE, Blendis LM, Medline A. Prognosis of alcoholic cirrhosis in the presence and absence of alcoholic hepatitis. Gastroenterology 1987; 92:208.
- Alexander JF, Lischner MW, Galambos JT. Natural history of alcoholic hepatitis. II. The long-term prognosis. Am J Gastroenterol 1971; 56:515.
- Powell WJ Jr, Klatskin G. Duration of survival in patients with Laennec's cirrhosis. Influence of alcohol withdrawal, and possible effects of recent changes in general management of the disease. Am J Med 1968; 44:406.
- Galambos JT. Alcoholic hepatitis: its therapy and prognosis. Prog Liver Dis 1972; 4:567.
- Teli MR, Day CP, Burt AD, et al. Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver. Lancet 1995; 346:987.
- Worner TM, Lieber CS. Perivenular fibrosis as precursor lesion of cirrhosis. JAMA 1985; 254:627.
- Nakano M, Worner TM, Lieber CS. Perivenular fibrosis in alcoholic liver injury: ultrastructure and histologic progression. Gastroenterology 1982; 83:777.
- Cuthbert JA, Arslanlar S, Yepuri J, et al. Predicting short-term mortality and long-term survival for hospitalized US patients with alcoholic hepatitis. Dig Dis Sci 2014; 59:1594.
- Brunt PW, Kew MC, Scheuer PJ, Sherlock S. Studies in alcoholic liver disease in Britain. I. Clinical and pathological patterns related to natural history. Gut 1974; 15:52.
- Luca A, García-Pagán JC, Bosch J, et al. Effects of ethanol consumption on hepatic hemodynamics in patients with alcoholic cirrhosis. Gastroenterology 1997; 112:1284.
- Muntaner L, Altamirano JT, Augustin S, et al. High doses of beta-blockers and alcohol abstinence improve long-term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding. Liver Int 2010; 30:1123.
- Veldt BJ, Lainé F, Guillygomarc'h A, et al. Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing. J Hepatol 2002; 36:93.
- Senanayake SM, Niriella MA, Weerasinghe SK, et al. Survival of patients with alcoholic and cryptogenic cirrhosis without liver transplantation: a single center retrospective study. BMC Res Notes 2012; 5:663.
- Friedmann PD. Clinical practice. Alcohol use in adults. N Engl J Med 2013; 368:365.
- Tang-Barton P, Vas W, Weissman J, et al. Focal fatty liver lesions in alcoholic liver disease: a broadened spectrum of CT appearances. Gastrointest Radiol 1985; 10:133.
- Bashist B, Hecht HL, Harley WD. Computed tomographic demonstration of rapid changes in fatty infiltration of the liver. Radiology 1982; 142:691.
- Lieber CS, Rubin E. Alcoholic fatty liver in man on a high protein and low fat diet. Am J Med 1968; 44:200.
- Niemelä O, Risteli J, Blake JE, et al. Markers of fibrogenesis and basement membrane formation in alcoholic liver disease. Relation to severity, presence of hepatitis, and alcohol intake. Gastroenterology 1990; 98:1612.
- REYNOLDS TB, GELLER HM, KUZMA OT, REDEKER AG. Spontaneous decrease in portal pressure with clinical improvement in cirrhosis. N Engl J Med 1960; 263:734.
- Runyon BA. Historical aspects of treatment of patients with cirrhosis and ascites. Semin Liver Dis 1997; 17:163.
- Verrill C, Markham H, Templeton A, et al. Alcohol-related cirrhosis--early abstinence is a key factor in prognosis, even in the most severe cases. Addiction 2009; 104:768.
- Mezey E. Interaction between alcohol and nutrition in the pathogenesis of alcoholic liver disease. Semin Liver Dis 1991; 11:340.
- Mendenhall CL, Anderson S, Weesner RE, et al. Protein-calorie malnutrition associated with alcoholic hepatitis. Veterans Administration Cooperative Study Group on Alcoholic Hepatitis. Am J Med 1984; 76:211.
- Stickel F, Hoehn B, Schuppan D, Seitz HK. Review article: Nutritional therapy in alcoholic liver disease. Aliment Pharmacol Ther 2003; 18:357.
- Moreno C, Deltenre P, Senterre C, et al. Intensive Enteral Nutrition Is Ineffective for Patients With Severe Alcoholic Hepatitis Treated With Corticosteroids. Gastroenterology 2016; 150:903.
- Singal AK, Shah VH. Therapeutic Strategies for the Treatment of Alcoholic Hepatitis. Semin Liver Dis 2016; 36:56.
- Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011; 365:1790.
- Caballería J, Parés A, Brú C, et al. Metadoxine accelerates fatty liver recovery in alcoholic patients: results of a randomized double-blind, placebo-control trial. Spanish Group for the Study of Alcoholic Fatty Liver. J Hepatol 1998; 28:54.
- Rizzo A, Breda A, Moretto F, et al. [Therapeutic use of metadoxine in chronic alcoholism. Double blind study of patients in a department of general medicine]. Clin Ter 1993; 142:243.
- Corsini G, Gelso E, Giuliano G. [Effects of metadoxine on main biohumoral changes induced by chronic alcoholism]. Clin Ter 1992; 140:251.
- Santoni S, Corradini P, Zocchi M, Camarri F. [Metadoxine in alcohol-related pathology]. Clin Ter 1989; 130:115.
- Mao YM, Zeng MD, Li YM, et al. [Capsule metadoxine in the treatment of alcoholic liver disease: a randomized, double-blind, placebo-controlled, multicenter study]. Zhonghua Gan Zang Bing Za Zhi 2009; 17:213.
- Rambaldi A, Gluud C. Propylthiouracil for alcoholic liver disease. Cochrane Database Syst Rev 2002; :CD002800.
- Ishii H, Kurose I, Kato S. Pathogenesis of alcoholic liver disease with particular emphasis on oxidative stress. J Gastroenterol Hepatol 1997; 12:S272.
- Mato JM, Cámara J, Fernández de Paz J, et al. S-adenosylmethionine in alcoholic liver cirrhosis: a randomized, placebo-controlled, double-blind, multicenter clinical trial. J Hepatol 1999; 30:1081.
- Rambaldi A, Gluud C. S-adenosyl-L-methionine for alcoholic liver diseases. Cochrane Database Syst Rev 2001; :CD002235.
- Rockey DC. Current and future anti-fibrotic therapies for chronic liver disease. Clin Liver Dis 2008; 12:939.
- Entzian P, Schlaak M, Seitzer U, et al. Antiinflammatory and antifibrotic properties of colchicine: implications for idiopathic pulmonary fibrosis. Lung 1997; 175:41.
- Molad Y. Update on colchicine and its mechanism of action. Curr Rheumatol Rep 2002; 4:252.
- Kershenobich D, Rojkind M, Quiroga A, Alcocer-Varela J. Effect of colchicine on lymphocyte and monocyte function and its relation to fibroblast proliferation in primary biliary cirrhosis. Hepatology 1990; 11:205.
- Kershenobich D, Vargas F, Garcia-Tsao G, et al. Colchicine in the treatment of cirrhosis of the liver. N Engl J Med 1988; 318:1709.
- Rambaldi A, Gluud C. Colchicine for alcoholic and non-alcoholic liver fibrosis and cirrhosis. Cochrane Database Syst Rev 2005; :CD002148.
- Rambaldi A, Jacobs BP, Iaquinto G, Gluud C. Milk thistle for alcoholic and/or hepatitis B or C liver diseases--a systematic cochrane hepato-biliary group review with meta-analyses of randomized clinical trials. Am J Gastroenterol 2005; 100:2583.
- NATURAL HISTORY AND PROGNOSTIC FACTORS
- General approach
- Nutritional therapy
- Alcoholic hepatitis
- Complications of cirrhosis
- Liver transplantation
- EXPERIMENTAL THERAPIES
- Complementary medicine
- SUMMARY AND RECOMMENDATIONS