Elsevier

Journal of Hepatology

Volume 69, Issue 1, July 2018, Pages 154-181
Journal of Hepatology

Clinical Practice Guidelines
EASL Clinical Practice Guidelines: Management of alcohol-related liver disease

https://doi.org/10.1016/j.jhep.2018.03.018Get rights and content

Summary

The harmful use of alcohol has been estimated to cause approximately 3.3 million deaths every year, corresponding to nearly 6% of all deaths globally. Therefore, the effective management and treatment of alcoholic liver disease is a pertinent public health issue. In the following Clinical Practice Guidelines, the latest data on the treatment and management of alcohol-related liver disease will be reviewed and up to date recommendations for clinical management will be provided.

Section snippets

Guideline development process

A panel of clinicians with an interest in liver disease and alcoholic liver disease (ALD), approved by the European Association for the Study of the Liver (EASL) Governing Board, wrote and discussed this Clinical Practice Guidelines (CPG) document between November 2016 and March 2017. The guidelines were independently peer reviewed, and all contributors to the CPG disclosed their conflicts of interest by means of a disclosure form provided by the EASL Office prior to work commencing. The EASL

Methods

These guidelines have been produced using evidence published before 1 October, 2017. Where possible, the level of evidence and recommendation are cited (Table 1). The evidence and recommendations in these guidelines have been graded using methods adapted from the grading of recommendations assessment development and evaluation (GRADE system). The strength of recommendations thus reflects the quality of underlying evidence. The GRADE system offers two grades of recommendation: strong or weak (

Terminology

The term alcoholic is stigmatising and undermines patient dignity and self-esteem. For this reason, these guidelines will use the following terms (Box 1):

However, at this point the term alcoholic hepatitis has become too standardised to change but may be reviewed in future guidelines.

Alcohol-related morbidity and mortality

According to the World Health Organization’s (WHO) 2014 report on noncommunicable diseases, harmful use of alcohol causes approximately 3.3 million deaths every year, corresponding to 5.9% of all deaths. Furthermore, 139 million disability-adjusted life years, or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption. The proportion of global deaths attributable to alcohol differs based on gender, with 7.6% of deaths among males and 4.0% of deaths among

Terminology and definitions

The publication of the DSM-V has been an important step forward to overcome the arbitrary differentiation between alcohol abuse and dependence, through the creation of the overarching concept of alcohol use disorder (AUD).30 This new concept is not only useful because it unifies the disorder, but also because it introduces a partially dimensional perspective into what has been traditionally called alcoholism. The categorical distinction between who is and who is not an alcoholic is not

Screening and clinical diagnosis of ALD

Diagnosis of ALD is usually suspected upon documentation of regular alcohol consumption of >20 g/d in females and >30 g/d in males together with the presence of clinical and/or biological abnormalities suggestive of liver injury. As a high proportion of patients with histological features of ALD do not express any clinical symptoms or laboratory abnormalities, asymptomatic patients consuming a critical amount of alcohol should undergo appropriate screening investigations.78 As previously

Definition and diagnosis

Alcoholic hepatitis is a distinct clinical syndrome characterised by the recent onset of jaundice with or without other signs of liver decompensation (i.e. ascites and/or encephalopathy) in patients with ongoing alcohol abuse.176 It is not uncommon for patients to have ceased alcohol consumption days or weeks before the onset of symptoms. Underlying this clinical syndrome is steatohepatitis, a disease defined histologically by steatosis, hepatocyte ballooning, and an inflammatory infiltrate

Alcohol-related fibrosis

Excessive alcohol consumption may induce a wide spectrum of lesions that include pure alcoholic steatosis, steatohepatitis, progressive liver fibrosis, cirrhosis and HCC.231 Above a daily consumption of 30 g/day, or a weekly consumption above seven units in women and 14 units in men,232 the risk of developing ALD is increased.233 At a daily intake of 100 g/day the relative risk reaches 26.234 Pure hepatic steatosis, often asymptomatic and overlooked, is almost constant in individuals consuming

Trends in liver transplantation of ALD

Liver transplantation (LT) is the most effective therapeutic option for patients with end-stage liver disease, with post-transplant patient and graft survival of around 80–85% at one year. Liver outcomes after LT in patients with AUD have improved, with graft and patient survival similar to those seen after transplantation for other aetiologies.[311], [312] Although only a minority of patients with AUD meet the rigorous criteria required of LT candidates, the number of transplantations done for

Conflict of interest

Mark Thursz reports grant support from Vital therapies; consultant/advisory roles for Gilead, AbbVie, CN-Bio and MSD; sponsored lectures for Gilead, BMS and AbbVie. Antoni Gual reports grant support from Lundbeck, consultant/advisory roles for D&A Pharma and Lundbeck; sponsored lectures for D&A Pharma and Lundbeck. Christophe Moreno reports grant support from Gilead; consultant/advisory roles for Gilead and Promethera; performance of Gilead sponsored clinical trial in alcoholic hepatitis.

Acknowledgements

We would like to thank the reviewers of this Clinical Practice Guideline for their time and critical reviewing: EASL Governing Board, Ewan Forrest, Fabio Caputo and Vijay Shah.

References (360)

  • R. de Franchis et al.

    Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension

    J Hepatol

    (2015)
  • D.W. Crabb et al.

    Standard definitions and common data elements for clinical trials in patients with alcoholic hepatitis: recommendation From the NIAAA alcoholic hepatitis consortia

    Gastroenterology

    (2016)
  • D.M. Levin et al.

    Nonalcoholic liver disease. Overlooked causes of liver injury in patients with heavy alcohol consumption

    Am J Med

    (1979)
  • J.H. Lefkowitch

    Morphology of alcoholic liver disease

    Clin Liver Dis

    (2005)
  • M.R. Teli et al.

    Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver

    Lancet

    (1995)
  • W.W. Yip et al.

    Alcoholic liver disease

    Semin Diagn Pathol

    (2006)
  • C. Lackner et al.

    Ballooned hepatocytes in steatohepatitis: the value of keratin immunohistochemistry for diagnosis

    J Hepatol

    (2008)
  • K. Zatloukal et al.

    From Mallory to Mallory-Denk bodies: what, how and why?

    Exp Cell Res

    (2007)
  • M. Colombat et al.

    Portal lymphocytic infiltrate in alcoholic liver disease

    Hum Pathol

    (2002)
  • WHO. GLOBAL STATUS REPORT on noncommunicable diseases 2014. WHO Library Cataloguing-in-Publication Data;...
  • OECD. Alcohol consumption among adults. In: Health at a Glance...
  • Shield KDR, M.M., Rehm, J. Public health successes and missed opportunities Trends in alcohol consumption and...
  • OECD. Tackling Harmful Alcohol Use: Economics and Public Health Policy. Paris...
  • G. Bell et al.

    Alcohol and death certification: a survey of current practice and attitudes

    Br Med J

    (1987)
  • SANCO D. Alcohol-related harm in Europe: Key Data, Factsheet. In: SANCO D, ed. Belgium...
  • Rabinovich L, Brutscher P-B, de Vries H, Tiessen J, Clift J, Reding A. The affordability of alcoholic beverages in the...
  • DHHS, DoA. 2015–2020 Dietary Guidelines for Americans. In: 8th ed....
  • (WHO) WHO. Food based dietary guidelines....
  • J. Rehm et al.

    The relationship between different dimensions of alcohol use and the burden of disease-an update

    Addiction

    (2017)
  • G. Corrao et al.

    Alcohol and coronary heart disease: a meta-analysis

    Addiction

    (2000)
  • A.L. Klatsky

    Alcohol and cardiovascular diseases: where do we stand today?

    J Intern Med

    (2015)
  • V. Bagnardi et al.

    Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis

    Br J Cancer

    (2015)
  • J. Rehm et al.

    Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis

    Drug Alcohol Rev

    (2010)
  • F. Aberg et al.

    Binge drinking and the risk of liver events: A population-based cohort study

    Liver Int

    (2017)
  • S. Masson et al.

    Clinical but not histological factors predict long-term prognosis in patients with histologically advanced non-decompensated alcoholic liver disease

    Liver Int

    (2014)
  • A.C. Wagenaar et al.

    Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies

    Addiction

    (2009)
  • A.C. Wagenaar et al.

    Effects of alcohol tax and price policies on morbidity and mortality: a systematic review

    Am J Public Health

    (2010)
  • T. Stockwell et al.

    Minimum alcohol prices and outlet densities in British Columbia, Canada: estimated impacts on alcohol-attributable hospital admissions

    Am J Public Health

    (2013)
  • Forum SGotEAaH. Does marketing communication impact on the volume and patterns of consumption of alcoholic beverages,...
  • P. Anderson et al.

    Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies

    Alcohol Alcohol

    (2009)
  • C. Verrill et al.

    Are the opportunities to prevent alcohol related liver deaths in the UK in primary or secondary care? A retrospective clinical review and prospective interview study

    Subst Abuse Treat Prev Policy

    (2006)
  • P.A. Cook et al.

    Evaluation of work-based screening for early signs of alcohol-related liver disease in hazardous and harmful drinkers: the PrevAIL study

    BMC Public Health

    (2015)
  • N. Sheron et al.

    Feasibility of detection and intervention for alcohol-related liver disease in the community: the Alcohol and Liver Disease Detection study (ALDDeS)

    Br J Gen Pract

    (2013)
  • C.S. Voican et al.

    Transient elastography alone and in combination with FibroTest((R)) for the diagnosis of hepatic fibrosis in alcoholic liver disease

    Liver Int

    (2017)
  • S. Hazeldine et al.

    Alcoholic liver disease - the extent of the problem and what you can do about it

    Clin Med

    (2015)
  • Association“ AP. American Psychiatric Association Substance use and addiction-related disorders. In: Diagnostic and...
  • J. Rehm et al.

    Alcohol use disorders in primary health care: what do we know and where do we go?

    Alcohol Alcohol

    (2016)
  • S. Zakhari et al.

    Determinants of alcohol use and abuse: Impact of quantity and frequency patterns on liver disease

    Hepatology

    (2007)
  • P. Barrio et al.

    Self-management and shared decision-making in alcohol dependence via a mobile app: a pilot study

    Int J Behav Med

    (2017)
  • J.B. Saunders et al.

    Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II

    Addiction

    (1993)
  • Cited by (558)

    View all citing articles on Scopus
    View full text