Alcohol‑related liver disease (ALD)
Alcohol‑related liver disease is a spectrum from simple steatosis through alcoholic hepatitis to progressive fibrosis and cirrhosis with portal‑hypertension complications. In the emergency department (ED) priorities are to recognise at‑risk patients, identify decompensation or severe alcoholic hepatitis, stabilise and treat immediate complications, calculate severity to guide steroid consideration, provide supportive care (including thiamine and nutrition) and involve hepatology early where indicated (NICE CG100, NG50).
Key clinical states
- Steatosis (fatty liver): common, often asymptomatic, and reversible with abstinence.
- Alcoholic hepatitis (AH): acute inflammatory liver injury after heavy drinking; severity ranges from mild to life‑threatening multi‑organ dysfunction and may occur with or without cirrhosis.
- Alcoholic cirrhosis: end‑stage fibrosis with portal hypertension (ascites, variceal bleeding, encephalopathy), impaired synthetic function and increased susceptibility to infection.
Pathophysiology
Ethanol is oxidised to acetaldehyde and acetate via alcohol dehydrogenase (ADH), CYP2E1 and catalase pathways. These reactions increase the NADH:NAD+ ratio, generate reactive oxygen species and produce acetaldehyde adducts that promote oxidative stress, inflammation and fibrogenesis. Genetic polymorphisms and co‑existing liver disease (notably hepatitis C) increase susceptibility and accelerate progression.
When to suspect ALD in the ED
- Any patient with heavy or prolonged alcohol use presenting with jaundice, ascites, confusion, gastrointestinal bleeding, hypotension, sepsis or worsening renal function.
- New abnormal liver function tests, especially a raised bilirubin and an AST:ALT ratio >1 (an AST:ALT...