Treatment Guideline Chart

Alcohol-related liver disease consists of a clinical-histologic spectrum which includes hepatic steatosis, alcoholic hepatitis and cirrhosis with its various complications.
Signs of alcohol abuse and hepatic injury include malnutrition and muscle wasting, cutaneous telangiectasia, palmar erythema, finger clubbing, Dupuytren's contracture, peripheral neuropathy, parotid gland enlargement and signs of gynecomastia and hypogonadism may also be present. Patient may also be asymptomatic.


Alcohol-related%20liver%20disease Signs and Symptoms

Signs and Symptoms

Patient may present with signs and symptoms related to portal hypertension:

  • Abdominal wall collaterals
  • Ascites
  • Hepatic encephalopathy
  • Splenomegaly
  • Venous hum

Signs of Alcohol Abuse and Hepatic Injury

  • Malnutrition and muscle wasting
  • Jaundice
  • Cutaneous telangiectasia
  • Palmar erythema
  • Finger clubbing
  • Dupuytren’s contracture
  • Rhinophyma
  • Spider angioma
  • Peripheral neuropathy
  • Parotid gland enlargement
  • Signs of gynecomastia and hypogonadism may also be present


  • Patient may be asymptomatic
  • Hepatomegaly, which is the most common sign in patients with alcohol-related liver disease (ALD)
  • Hepatic bruit
  • Alcohol withdrawal (eg tremors, tachycardia, agitation, delirium tremens)
  • Anorexia, weight loss
  • Systemic inflammatory response syndrome (SIRS) (≥2 of the following: Heart rate >100 beats/minute, respiratory rate >12 breaths/minute, temperature >38°C or <36°C, WBC count >12,000 or <4000 mm)


  • Leading cause of acute and chronic liver failure, cirrhosis and liver cancer   
  • One of the leading causes of liver transplantation 
  • Approximately 20% of alcoholics have alcoholic hepatitis   
  • Causes approximately 6% of all deaths worldwide    
    • Alcoholic cirrhosis accounts for approximately 10% of alcohol-related deaths worldwide


  • ALD results from complex interaction of behavioral, environmental and genetic factors   
    • Heavy alcohol consumption leads to hepatic fat accumulation by affecting the redox mechanisms in the liver through interference with transcription factors that regulate fatty acid synthesis and oxidation leading to increased fatty acid synthesis and reduced fatty acid oxidation   
    • Gut permeability changes resulting to increased portal vein endotoxin, innate immune response activation, liver inflammation, injury, apoptosis and necrosis, and fibrosis thereby activating the cytokine and oxidative stress cascades leading to liver injury 

Risk Factors

Cofactors in the Development of ALD

  • The amount (>30 g/day) and type of alcohol ingested and drinking pattern (eg daily drinking, binge drinking)
    • Red wine was less likely to be associated with cirrhosis than other alcoholic drinks 
  • Genetic factors
    • Genetic variants PNPLA3, TM6SF2, MBOAT7, HSD17B13 
    • Rate of alcohol metabolism plays a role
  • Gender
    • Women are more susceptible compared to men
  • Diet and nutrition
    • Undernutrition
    • Overnutrition and obesity are established independent risk factors for hepatic steatosis and steatohepatitis
  • Cigarette smoking
  • Co-morbid conditions (eg metabolic dysfunction-associated steatohepatitis [MASH], metabolic dysfunction-associated steatotic liver disease [MASLD], viral hepatitis and hemochromatosis)
    • Concomitant hepatitis B virus (HBV) infection accelerates the progression of ALD and may hasten mortality
    • Hepatitis C virus (HCV) infection increases probability of development of cirrhosis by 8- to 10-fold and accelerates progression of ALD
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