Alcohol-associated liver disease is the leading cause of cirrhosis in the United States and has become the top indication for liver transplantation since direct-acting antivirals allowed for cure of hepatitis C. The COVID-19 pandemic compounded existing concerns about a rising prevalence of alcohol-associated hepatitis, with a notable increase in women in their 30s and 40s. Insufficient access to health care continues to exacerbate socioeconomic disparities in screening and treatment. People identifying as American Indian or Alaska Native have had the greatest increase in mortality due to alcohol-associated liver disease. Alcohol use screening is essential for all adults. Abstinence from alcohol remains the cornerstone intervention for alcohol-associated liver disease, although pharmacotherapies are under evaluation. Noninvasive liver disease assessment, including serum and imaging modalities, is expanding access to advanced liver disease evaluation in primary care settings. Other causes of substance-based liver injury include prescription and nonprescription medications, herbal products, and dietary supplements.
Green EW. Hepatitis Overview: Alcohol-Associated Liver Disease and Drug-Induced Liver Injury. FP Essent. 2026;566:25-36.
Case 3. PS is a 27-year-old woman with minimal medical history who is establishing care. She has never used tobacco and drinks a few alcoholic beverages after work.
Alcohol-Associated Liver Disease and Hepatitis
EPIDEMIOLOGY
Alcohol-associated liver disease is the leading cause of cirrhosis and liver-related mortality in the United States, contributing to one-half of cirrhosis deaths at a rate of 7.3 per 100,000 people annually.1 Liver transplantation related to alcohol-associated liver disease has increased for both chronic alcohol-associated cirrhosis and acute severe alcohol-associated hepatitis, with alcohol-induced liver injury being the chief indication for liver transplantation since the advent of direct-acting antiviral therapy for hepatitis C.2
Although most people who drink alcohol beyond the limits recommended by the National Institute of Alcohol Abuse and Alcoholism develop steatosis, most will not develop alcohol-related steatohepatitis or cirrhosis. The true prevalence of these conditions is obscured by lack of detection, which is typically limited to advanced disease. The US Preventive Services Task Force recommends screening all adults 18 and older, including pregnant women, in the primary care setting for unhealthy alcohol use and providing brief behavioral counseling interventions and referral to treatment as indicated, although many professional societies have moved to endorse the idea that there is no safe amount of alcohol consumption.3–6
CHANGES IN DEMOGRAPHICS
Across all demographics, alcohol consumption has increased since 2000, with a pronounced acceleration around the COVID-19 pandemic. Mortality related to alcohol-associated liver disease has shown a similar increase.7 Individuals ages 25 to 34 years demonstrated a disproportionate rise in mortality between 2009 and 2016 due to alcohol use disorder and alcohol-associated liver disease, compared with other age groups during this period.8 Women, especially those in their 30s to 40s, have had the most marked increase in alcohol intake and concomitant alcohol-associated liver disease mortality.9,10 Important factors include physiologic vulnerability, compounded by increased alcohol consumption associated with changes in women’s social roles and shifts in advertisement targeting.11,12 Serious outcomes, such as liver-related mortality in women, are further complicated by historic disparities in liver transplantation.13 People who have undergone bariatric surgery are another population at higher risk of alcohol use disorder and alcohol-associated liver disease.14,15
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