Alcohol-Associated Liver Disease: Guidelines From the American College of Gastroenterology

Approximately 15 in 100,000 people die of cirrhosis annually in the United States, and one-half of these deaths are associated with alcohol use. The prevalence of severe forms of alcohol-associated liver disease (ALD) is increasing in younger people, women, and Hispanic and Native American people. Liver transplants for alcohol-associated hepatitis have increased fourfold in those younger than 40 years. Rates of alcohol use and ALD-related mortality increased during the COVID-19 pandemic. The American College of Gastroenterology has released guidelines for management of ALD.

The primary risk factor for ALD is heavy alcohol use; however, only up to 20% of people with heavy alcohol use develop cirrhosis, which is likely due to one or more genetic predispositions. Some large cohort studies suggest that wine and beer consumption is associated with lower rates of ALD than drinking liquor.

Smoking at least one pack of cigarettes per day independently increases the risk of cirrhosis from ALD by threefold, possibly more in women.

In people who drink, the presence of obesity and diabetes increase the risk of liver disease. For patients with metabolic dysfunction–associated steatotic liver disease (MASLD), alcohol use leads to more liver injury. Although bariatric surgery can reverse the injury from MASLD, bariatric surgery often leads to the development of alcohol use disorder and may lead to ALD.

Screening for Alcohol Use Disorder

Although patients should be screened at all health care encounters, screening patients with mental health conditions, gastrointestinal conditions, hypertension, and minor injury is more likely to identify harmful alcohol use. The three-question Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is recommended because of its similar accuracy to the longer AUDIT tool.

In addition to blood alcohol concentration, direct alcohol biomarkers, including ethyl glucuronide, ethyl sulfate, and phosphatidylethanol, are useful for confirming alcohol use within the window for each test. Indirect biomarkers, such as gamma-glutamyltransferase and mean corpuscular volume, are of limited use.

Noninvasive Testing

In patients with asymptomatic ALD, blood-based and radiologic tests are recommended to assess fibrosis severity. However, the relationship between ALD and fibrosis is not as clear as with other causes of liver disease. The Fibrosis-4 test has a sensitivity of 80% to 90% and can be used to exclude advanced fibrosis. For higher specificity (80%–90%), the enhanced liver fibrosis score and FibroTest may be used, but these tests are not as widely available and cost more. Vibration-controlled transient elastography can be used for diagnosis of advanced fibrosis.