Eduovisual
Gastrointestinal
Alcohol-associated liver disease: management and abstinence support
— Alcohol-associated liver disease (ALD) encompasses a histologic and clinical spectrum: hepatic steatosis → alcohol-associated steatohepatitis → progressive fibrosis → cirrhosis → hepatocellular carcinoma (HCC)
— Alcohol-associated hepatitis (AH) is a distinct acute-on-chronic syndrome: rapid-onset jaundice (often <8 weeks), tender hepatomegaly, and AST-predominant transaminitis in a patient with heavy ongoing alcohol use
— Risk rises sharply at >3 drinks/day (men) or >2 drinks/day (women) sustained over years; one standard US drink = 14 g ethanol
— Women, Hispanic patients, those with obesity, HCV, smoking, and PNPLA3/TM6SF2 variants progress faster at lower exposures
— ALD is now the leading indication for liver transplantation in the United States, having surpassed HCV
— Any patient with AST:ALT ratio ≥2 (both usually <300 U/L), macrocytosis (elevated MCV), low platelets, elevated GGT, or unexplained ascites/encephalopathy
— Outpatient: incidental LFT elevations on annual labs, preoperative panels, or pre-employment screens — always pair with AUDIT-C
— Inpatient: new jaundice + leukocytosis in a drinker should not be reflexively attributed to cholangitis; consider AH
— USPSTF: screen all adults ≥18 for unhealthy alcohol use with AUDIT-C or single-item screen; deliver brief behavioral counseling for those who screen positive
— Pregnant patients: ask at every visit; no safe quantity established
— Compensated cirrhosis 10-yr mortality ~20%; once decompensated (ascites, variceal bleed, HE, jaundice), 1-yr mortality jumps to 20–50%
— Severe AH (MELD >20 or Maddrey ≥32) carries 30–50% 90-day mortality without therapy
Board pearl: AST:ALT >2 with AST rarely above 300 is the classic ALD fingerprint — values >500 should push you toward acetaminophen, ischemic, or viral hepatitis instead.
— Asymptomatic steatosis: Incidental hepatomegaly or LFT bump; patient feels well; reversible with abstinence in weeks to months
— Alcohol-associated hepatitis (AH): Subacute jaundice, anorexia, low-grade fever, RUQ pain, tender hepatomegaly, often a recent intensification of drinking; SIRS criteria common even without infection
— Decompensated cirrhosis: Ascites, variceal bleeding, hepatic encephalopathy (HE), hepatorenal syndrome (HRS), or jaundice; may be the first presentation in someone who hid drinking
— Quantity, frequency, duration, last drink, prior withdrawal/seizures/DTs, prior detox or rehab admissions
— Use AUDIT-C (3 items, score ≥4 men / ≥3 women = positive) for screening; full AUDIT-10 for severity
— Document DSM-5 AUD criteria (2–3 mild, 4–5 moderate, ≥6 severe) — this drives MAT eligibility and transplant evaluation
— Tobacco (synergistic HCC risk), benzodiazepines, opioids, stimulants, cannabis
— Depression, anxiety, PTSD, bipolar — all worsen relapse risk and require co-treatment
— Hematemesis or melena → variceal bleed until proven otherwise
— Confusion, asterixis, day-night reversal → HE; check ammonia only if diagnosis uncertain (treat clinically)
— Fever + ascites → spontaneous bacterial peritonitis (SBP); paracentesis is mandatory
— Family members often reveal true intake; obtain with patient consent
— Review prescription monitoring program (PDMP) for concurrent benzodiazepine/opioid scripts before prescribing
Step 3 management: In any new patient with suspected ALD, the first three orders should be CBC, comprehensive metabolic panel with INR, and an AUDIT-C — quantification of drinking is a billable, exam-rewarded action that drives every subsequent decision including withdrawal prophylaxis and pharmacotherapy.
— Cachexia with temporal and proximal muscle wasting (sarcopenia is an independent mortality predictor)
— Parotid enlargement, Dupuytren contractures, palmar erythema
— Fetor hepaticus in advanced disease
— Spider angiomata (>3 in SVC distribution highly specific), gynecomastia, testicular atrophy, loss of axillary/pubic hair (hyperestrogenism)
— Caput medusae, abdominal wall venous distension
— Asterixis: flapping tremor with wrists dorsiflexed — hallmark of HE
— Terry nails (proximal white, distal pink), clubbing
— Tender hepatomegaly is classic in AH; small, nodular, shrunken liver suggests established cirrhosis
— Splenomegaly + abdominal collaterals = portal hypertension
— Fluid wave/shifting dullness for ascites; bedside ultrasound increases sensitivity
— Grade 0 minimal → I (mild confusion, sleep reversal) → II (lethargy, asterixis) → III (somnolent but rousable) → IV (coma)
— Always check for focal deficits to exclude intracranial hemorrhage in falls/coagulopathy
— Hyperdynamic circulation: wide pulse pressure, warm extremities, bounding pulses, resting tachycardia
— Cirrhotic cardiomyopathy: blunted contractile response to stress, prolonged QT — relevant before TIPS or transplant
— Hypotension + AKI + bland sediment in cirrhosis = consider HRS-AKI after volume challenge with 1 g/kg/day albumin × 2 days
— Peripheral edema and ascites coexist with intravascular depletion; JVP is unreliable; trend lactate, MAP, urine output, and creatinine
Board pearl: Asterixis is not specific to hepatic encephalopathy — uremia, CO₂ narcosis, and severe heart failure also produce it. In ALD with confusion, exclude hypoglycemia, Wernicke's, subdural hematoma, and infection before attributing solely to HE.
— CBC: macrocytic anemia (folate, B12, direct toxicity), thrombocytopenia (splenic sequestration, marrow suppression), leukocytosis in AH (can mimic infection)
— CMP: AST > ALT (ratio ≥2), both typically <300 U/L; elevated total bilirubin (direct predominant); low albumin; hyponatremia (poor prognosis)
— GGT elevated and supports alcohol etiology but is nonspecific
— INR/PT: prolongation signals hepatic synthetic dysfunction; do not "correct" with FFP unless bleeding
— Lipase, lactate, ammonia (selective), magnesium, phosphate, glucose
— Hepatitis B surface antigen, surface antibody, core antibody
— Hepatitis C antibody with reflex RNA
— Iron studies (hemochromatosis), ceruloplasmin in <55 yo (Wilson), ANA/ASMA/IgG (autoimmune hepatitis), AMA (PBC), alpha-1 antitrypsin level
— Acetaminophen level if any altered mental status or co-ingestion suspected
— PEth (phosphatidylethanol): whole blood, detects use up to 3–4 weeks; high specificity
— Urinary ethyl glucuronide (EtG)/ethyl sulfate (EtS): 3–5 day window; false positives with hand sanitizer/mouthwash exposure
— Serum ethanol: only recent use (hours)
— RUQ ultrasound with Doppler is first-line: steatosis, nodular liver, splenomegaly, ascites, portal/hepatic vein patency, screens for HCC
— Cross-sectional imaging (CT/MRI) for nodules ≥1 cm on US, suspected portal vein thrombosis, or staging
— Transient elastography (FibroScan): noninvasive fibrosis staging; values >12.5 kPa suggest cirrhosis (but inflammation falsely elevates)
Step 3 management: Order the full chronic liver disease panel on the first visit — finding a treatable coexisting cause (HCV, hemochromatosis) changes prognosis even if alcohol is the dominant driver.
— Maddrey discriminant function (MDF): 4.6 × (PT − control PT) + total bilirubin; ≥32 = severe AH, indication to consider corticosteroids
— MELD-Na: preferred modern score; MELD ≥20 defines severe AH and predicts 90-day mortality; also drives transplant prioritization
— Glasgow Alcoholic Hepatitis Score (GAHS), ABIC score: alternative tools
— Lille score on day 4 or 7 of steroids: ≥0.45 = nonresponse → stop steroids and consider transplant evaluation
— Child-Turcotte-Pugh (bilirubin, albumin, INR, ascites, HE) categorizes severity (A/B/C)
— AFP + abdominal US every 6 months for HCC surveillance once cirrhosis established
— Screening EGD at diagnosis of cirrhosis to identify varices; nonselective beta-blocker or band ligation per size/red wale signs
— FIB-4 and AST-to-platelet ratio index (APRI): cheap, validated; FIB-4 >3.25 has high specificity for advanced fibrosis
— Enhanced Liver Fibrosis (ELF) test and MR elastography for selected cases
— Indicated when diagnosis uncertain, when steroids being considered but presentation atypical, or when alternative etiology suspected
— Transjugular route preferred with coagulopathy/ascites; allows hepatic venous pressure gradient (HVPG) — HVPG >10 mm Hg = clinically significant portal hypertension, >12 = variceal bleed risk
— Blood cultures, urine culture, CXR, diagnostic paracentesis (ascites PMN ≥250/mm³ = SBP) — must rule out before steroids
— Procalcitonin unreliable in cirrhosis
Board pearl: The Lille score at day 7 is the decision point on steroid continuation — a nonresponder (≥0.45) has ~75% 6-month mortality and should be referred urgently for early liver transplant evaluation at experienced centers.
— Steatosis: abstinence + nutrition; reversible
— Steatohepatitis without severe AH: abstinence, nutrition, treat AUD, no steroids
— Severe AH (MDF ≥32 or MELD ≥20): rule out infection/GI bleed → consider prednisolone 40 mg/day × 28 days with Lille reassessment day 7
— Compensated cirrhosis: abstinence, screen for varices/HCC, vaccinate, manage comorbidities
— Decompensated cirrhosis: treat complications, expedite transplant evaluation if candidate
— Complete abstinence is the single most important intervention — improves survival at every disease stage
— Nutritional support: target 35 kcal/kg/day and 1.2–1.5 g/kg/day protein; do not restrict protein even in HE; nocturnal snack reduces muscle catabolism
— Thiamine 100 mg IV/PO daily × ≥3 days before glucose to prevent Wernicke encephalopathy; add folate, multivitamin, replete magnesium/phosphate
— Withdrawal prophylaxis: symptom-triggered benzodiazepines via CIWA-Ar; lorazepam or oxazepam preferred in significant liver disease (no active metabolites, no oxidative metabolism)
— Vaccinate: hepatitis A, hepatitis B, pneumococcal, influenza, COVID-19, zoster
— Mild LFT elevation + reliable patient + no decompensation → outpatient brief intervention + AUD pharmacotherapy + 2-week follow-up
— Jaundice, ascites, encephalopathy, or MELD ≥20 → admit
— Active withdrawal with prior seizures/DTs, hemodynamic instability, or pregnancy → admit, often ICU
CCS pearl: On a CCS case of suspected AH, advance the clock only after you have ordered: CBC, CMP with INR, lipase, ammonia (if AMS), blood and urine cultures, diagnostic paracentesis if ascites, RUQ US, hepatitis panel, thiamine + folate + MVI, and IV fluids — then reassess at 6–12 hours before initiating steroids.
— Naltrexone: oral 50 mg/day or IM 380 mg monthly; first-line in most patients; reduces heavy drinking days and craving; contraindicated in opioid use (precipitates withdrawal) and in acute hepatitis or hepatic failure (black box warning); safe in compensated stable LFTs
— Acamprosate: 666 mg PO TID; supports maintenance of abstinence; renally cleared — adjust for CrCl 30–50, contraindicated if CrCl <30; preferred when active liver disease precludes naltrexone
— Disulfiram: 250 mg/day; aversive (acetaldehyde accumulation); requires highly motivated patient with social support; avoid in significant cardiac disease, psychosis, advanced cirrhosis
— Gabapentin (especially with insomnia, anxiety, mild withdrawal); caution with sedation/misuse potential
— Topiramate (cognitive side effects; weight loss as bonus); not in stones, pregnancy
— Baclofen: the only AUD agent with safety data in decompensated cirrhosis; start 5 mg TID
— Prednisolone 40 mg PO daily × 28 days (use prednisolone, not prednisone, due to impaired conversion)
— Reassess with Lille score at day 7 — if ≥0.45 (nonresponder), discontinue steroids
— Contraindications: active GI bleed, uncontrolled infection, AKI/HRS unresponsive to treatment, HBV reactivation risk
— Pentoxifylline is no longer recommended as first-line (STOPAH trial negative); N-acetylcysteine + steroids may reduce short-term infection but mortality benefit unclear
— Lactulose ± rifaximin for HE
— Nonselective beta-blocker (propranolol, nadolol, carvedilol preferred) for varices; avoid if refractory ascites or SBP with hypotension
— Albumin 1.5 g/kg day 1 + 1 g/kg day 3 with SBP; ceftriaxone 2 g IV daily × 5–7 days
Board pearl: Naltrexone is contraindicated in acute alcoholic hepatitis and decompensated cirrhosis; reach for acamprosate or baclofen — and remember acamprosate fails the kidneys, baclofen tolerates the liver.
— Diagnostic paracentesis is mandatory in every cirrhotic with new ascites or any clinical change (fever, AMS, AKI, abdominal pain) — do not delay for INR or platelets
— Send cell count with differential, total protein, albumin (calculate SAAG; ≥1.1 confirms portal HTN), culture in blood culture bottles at bedside
— Large-volume paracentesis >5 L: give albumin 6–8 g per liter removed to prevent post-paracentesis circulatory dysfunction
— Screening EGD at cirrhosis diagnosis; if small varices and high-risk features or any medium/large varices → primary prophylaxis with NSBB or band ligation
— Acute variceal bleed: octreotide drip, ceftriaxone, urgent EGD within 12 hours, band ligation; rescue with balloon tamponade or TIPS
— Indications: refractory variceal bleeding, refractory ascites, HRS-AKI bridge, hepatic hydrothorax
— Contraindications: severe HE, CHF/pulmonary HTN, MELD ≥18 (relative — higher mortality), uncorrected sepsis
— For AKI with refractory acidosis, hyperkalemia, volume overload; bridge in transplant candidates
— Listed at MELD ≥15; severe AH nonresponders increasingly considered for early transplant at experienced centers — outcomes now equal to other indications
— Traditional "6-month abstinence rule" is no longer absolute; current selection emphasizes psychosocial assessment, AUD treatment engagement, and support system
— Surveillance US ± AFP every 6 months once cirrhotic; treat with resection, ablation, TACE, Y-90, systemic therapy, or transplant per BCLC stage
Step 3 management: Any cirrhotic admitted with new ascites, fever, AMS, or AKI gets a diagnostic paracentesis within 12 hours — failure to tap is a documented quality-measure miss and a frequent vignette trap.
— Lower lean body mass → higher BAC per drink; "moderate" intake (1 drink/day) may already be hepatotoxic
— Polypharmacy: APAP-containing combinations, NSAIDs, sedatives compound hepatic/renal injury — review every med
— Falls + coagulopathy = subdural hematoma risk; lower threshold for head CT with confusion
— Withdrawal in elderly often atypical (delirium without tremor); favor lorazepam (no active metabolite, shorter half-life) over chlordiazepoxide/diazepam
— Cognitive comorbidity complicates AUD counseling; involve family/caregivers and screen for dementia after 30 days of abstinence (reversible component common)
— Acamprosate: adjust to 333 mg TID for CrCl 30–50; contraindicated <30
— Naltrexone: no renal adjustment but use cautiously in severe renal disease
— Gabapentin: dose-adjust to CrCl; risk of sedation and falls
— HRS-AKI: midodrine + octreotide + albumin outpatient bridge; terlipressin (FDA-approved) or norepinephrine + albumin inpatient
— Avoid NSAIDs, aminoglycosides, iodinated contrast when possible
— Avoid acetaminophen >2 g/day in cirrhosis; APAP up to 2 g/day acceptable and preferred over NSAIDs/opioids for pain
— Benzodiazepines: lorazepam, oxazepam, temazepam ("LOT") are conjugated only and safer; avoid diazepam, chlordiazepoxide in severe disease
— Statins are safe and beneficial in compensated cirrhosis (mortality benefit signal); hold if decompensated
— Opioids: prefer low-dose hydromorphone or fentanyl; avoid morphine (active metabolites accumulate); start low, go slow
— PPIs: minimize duration — associated with SBP and C. difficile in cirrhotics
Board pearl: In cirrhosis, acetaminophen ≤2 g/day is the safest analgesic — NSAIDs cause AKI, sodium retention, and variceal bleeding; opioids precipitate encephalopathy.
— No safe level of alcohol in pregnancy; counsel abstinence preconception and throughout
— Fetal alcohol spectrum disorders: smooth philtrum, thin vermilion border, short palpebral fissures, growth restriction, neurodevelopmental delay
— Screen every pregnant patient with T-ACE or AUDIT-C; mandatory at first prenatal visit
— Withdrawal in pregnancy is dangerous to fetus; inpatient management with short-acting benzodiazepines (lorazepam) preferred over no treatment
— Naltrexone: limited data, generally avoided; acamprosate: animal data concerning; disulfiram: contraindicated (teratogenic)
— Nonpharmacologic support, CBT, motivational interviewing are mainstays
— Postpartum: relapse risk peaks; if breastfeeding, advise no alcohol or "pump and discard" ≥2 hours per drink
— Screen with CRAFFT tool annually starting at age 9–11 per AAP
— Earlier age of first use predicts AUD; brief motivational interviewing in primary care has evidence base
— Naltrexone has limited pediatric data but is used in adolescents ≥18 with severe AUD
— Develop ALD at lower cumulative doses and faster fibrosis progression than men (lower gastric ADH, body composition, estrogen effects)
— Higher risk of breast cancer with any alcohol use — counsel explicitly
— Higher prevalence of AUD in some subgroups due to minority stress and access barriers; tailor culturally responsive care
— Lifelong abstinence required; monitor with PEth or EtG; relapse → graft loss
— Continue AUD pharmacotherapy and behavioral support indefinitely
Step 3 management: A pregnant patient who screens positive for unhealthy alcohol use gets brief intervention at every prenatal visit, social work referral, and—if drinking persists—admission for medically supervised withdrawal with lorazepam, not outpatient taper.
— Variceal hemorrhage: 20% mortality per episode; rebleed risk 60% within 1 year without prophylaxis
— Ascites: 50% 2-year mortality once present; refractory ascites 50% 6-month mortality
— Spontaneous bacterial peritonitis (SBP): PMN ≥250; treat with ceftriaxone + albumin; lifelong norfloxacin/SMX-TMP prophylaxis after episode
— Hepatic hydrothorax: right-sided transudative effusion; avoid chest tube (high mortality)
— Precipitants: GI bleed, infection, dehydration, constipation, electrolyte disturbance, sedatives, TIPS, dietary protein indiscretion
— Treatment: lactulose titrated to 2–3 soft stools/day; add rifaximin 550 mg BID for recurrent episodes
— Driving safety: counsel against driving with overt HE; many states require reporting
— Type 1/HRS-AKI: rapid doubling of creatinine; treat with albumin + terlipressin (or norepinephrine in ICU, or midodrine/octreotide on the floor)
— Avoid diuretics, nephrotoxins, large-volume paracentesis without albumin
— Elevated INR does not reflect bleeding risk reliably (balanced rebalance of pro- and anticoagulants); avoid prophylactic FFP
— Increased risk of portal vein thrombosis — consider anticoagulation case-by-case
— 1–3% annual incidence in alcohol-related cirrhosis; surveillance US ± AFP every 6 months
— Cardiomyopathy, atrial fibrillation ("holiday heart"), hemorrhagic stroke, pancreatitis, peripheral neuropathy, Wernicke-Korsakoff, osteoporosis, head/neck/esophageal/breast/colorectal cancers
— Malnutrition and sarcopenia are independent mortality predictors
Board pearl: Any cirrhotic with new altered mental status needs a workup for infection (especially SBP), GI bleed, electrolyte derangement, and intracranial bleed — do not just escalate lactulose without searching for the precipitant.
— Active variceal hemorrhage with hemodynamic instability or airway compromise
— Grade III–IV hepatic encephalopathy requiring airway protection
— Septic shock, especially with SBP
— HRS-AKI requiring vasopressors or RRT
— Severe alcohol withdrawal: DTs, seizures, hyperthermia, requirement for IV benzodiazepine infusion, or CIWA persistently >20 despite aggressive dosing
— Acute-on-chronic liver failure (ACLF) with ≥2 organ failures
— Severe AH with MELD ≥20 / MDF ≥32 without organ failure
— New decompensation (ascites, HE, jaundice) requiring diagnostic workup
— Withdrawal requiring scheduled benzodiazepines or significant comorbidity
— Inability to maintain PO intake; need for thiamine/electrolyte repletion
— Hepatology: all severe AH, decompensated cirrhosis, transplant evaluation candidates (MELD ≥15), refractory ascites, HCC, ACLF
— GI/endoscopy: variceal bleed, screening EGD
— IR: TIPS evaluation, paracentesis when bleeding risk concerns, HCC locoregional therapy
— Addiction medicine / psychiatry: for MAT initiation, dual diagnosis, refractory relapse, transplant psychosocial evaluation
— Social work and case management: housing, insurance, transport, AA/intensive outpatient referrals
— Palliative care: ACLF without transplant option, terminal HCC, refractory symptoms
— MELD ≥15 candidates, Lille nonresponders with severe AH, ACLF grade 2–3, large HCC within Milan/UCSF criteria
CCS pearl: On a CCS variceal bleed case, the order set is 2 large-bore IVs, type and crossmatch, IV octreotide bolus + infusion, IV ceftriaxone 1 g daily × 5–7 days, PPI drip, urgent GI consult for EGD within 12 hours, transfuse to Hb target ~7 g/dL — overtransfusion worsens portal pressure and rebleeding.
— ALT typically > AST (opposite of ALD) until cirrhosis develops
— Metabolic syndrome features; obesity, T2DM, dyslipidemia
— Overlap common: a patient may have both — quantify alcohol carefully
— Acute HCV/HBV: transaminases often >1000; check viral serologies
— Chronic HCV/HBV: moderate elevations; can synergize with alcohol to accelerate fibrosis
— HDV superinfection in HBV
— Acetaminophen: AST/ALT often >3000, hepatocellular pattern, low bilirubin early; check level + N-acetylcysteine
— Amoxicillin-clavulanate, isoniazid, methotrexate, amiodarone, statins (rarely), herbals (kava, green tea extract, ashwagandha)
— Take a detailed supplement history — patients often omit OTC
— Young or middle-aged women; ANA, ASMA, elevated IgG; can present with acute hepatitis or cirrhosis; biopsy: interface hepatitis
— Primary biliary cholangitis (PBC): middle-aged women, pruritus, elevated alkaline phosphatase, AMA positive
— Primary sclerosing cholangitis (PSC): male, IBD association, MRCP "beaded" ducts
— Hemochromatosis: elevated ferritin, transferrin saturation >45%; HFE C282Y testing
— Wilson disease: age <55, low ceruloplasmin, Kayser-Fleischer rings, elevated 24-hr urine copper
— Alpha-1 antitrypsin deficiency: low serum level, ZZ phenotype; consider in any unexplained cirrhosis
— "Shock liver": transient AST/ALT into thousands after hypotension; rapid normalization
Key distinction: AST > ALT with both <300 in a patient with macrocytosis and elevated GGT = alcohol; ALT > AST in a patient with BMI 34 and HbA1c 6.8% = MASLD; AST/ALT >1000 with low bilirubin = think acetaminophen or ischemic.
— Choledocholithiasis/cholangitis: Charcot triad (fever, jaundice, RUQ pain) + Reynolds pentad (add hypotension, AMS); cholestatic LFT pattern, dilated ducts on US; treat with ERCP + antibiotics
— Acute cholecystitis: Murphy sign, leukocytosis; HIDA scan if US equivocal
— Acute pancreatitis (often coexists with alcohol use): lipase >3× ULN; alcohol is the #2 cause behind gallstones
— Budd-Chiari syndrome: ascites + hepatomegaly + abdominal pain; Doppler shows hepatic vein outflow obstruction; often hypercoagulable
— Wernicke encephalopathy (ophthalmoplegia, ataxia, confusion) — treat empirically with high-dose thiamine
— Hypoglycemia, uremia, sepsis, intracranial hemorrhage, post-ictal state, drug intoxication/withdrawal
— Nonconvulsive status epilepticus — consider EEG in unexplained AMS
— Heart failure (elevated JVP, SAAG ≥1.1 but high total protein)
— Nephrotic syndrome (proteinuria), peritoneal carcinomatosis (SAAG <1.1), TB peritonitis, myxedema
— B12/folate deficiency, hypothyroidism, MDS, drugs (methotrexate, hydroxyurea, zidovudine), reticulocytosis
— ITP, TTP/HUS, DIC, heparin-induced, drug-induced, sepsis, marrow disorders, HIV
— Sepsis, thyrotoxicosis, sympathomimetic toxicity, anticholinergic toxicity, serotonin syndrome, NMS
Board pearl: Jaundice + fever + RUQ pain is cholangitis until proven otherwise — get LFTs (cholestatic pattern), RUQ US for dilated ducts, blood cultures, broad-spectrum antibiotics, and ERCP within 24–48 hours; don't anchor on alcoholic hepatitis just because the patient drinks.
— AUD pharmacotherapy started before discharge (acamprosate or naltrexone or baclofen depending on hepatic/renal function) — initiation in hospital dramatically improves uptake
— Thiamine 100 mg PO daily, folate 1 mg daily, multivitamin for ≥30 days
— Lactulose ± rifaximin if any HE episode
— Nonselective beta-blocker (carvedilol 6.25 mg BID preferred) for varices unless contraindicated
— SBP prophylaxis: ciprofloxacin 500 mg daily or SMX-TMP DS daily after first SBP episode, or with ascitic protein <1.5 g/dL plus risk factors
— Diuretics: spironolactone:furosemide 100:40 mg titrated for ascites; daily weights
— PPI only if true indication — minimize duration
— Vaccines: HAV, HBV, pneumococcal (PCV20 or PCV15+PPSV23), annual influenza, COVID-19, Tdap, zoster (≥50)
— NSAIDs, nephrotoxins, IV contrast when avoidable
— Benzodiazepines beyond withdrawal taper
— APAP >2 g/day in cirrhosis
— Sedating antihistamines, anticholinergics
— HCC: US ± AFP every 6 months in all cirrhotics
— EGD: every 2–3 years for no varices, every 1–2 years for small varices off NSBB
— Bone density: DEXA at cirrhosis diagnosis; vitamin D, calcium
— Dental, dermatology, depression screening annually
— Smoking cessation (synergistic HCC and cardiovascular risk)
— Weight management, exercise to address concurrent MASLD
— Coffee consumption (2–3 cups/day) associated with lower fibrosis progression — reasonable to encourage
— Hepatotoxic supplements: counsel against kava, comfrey, chaparral, high-dose green tea extract
Step 3 management: Every ALD discharge should pair AUD pharmacotherapy + behavioral referral (AA, IOP, addiction clinic) — pharmacotherapy alone or counseling alone is inferior to combined treatment, and uninitiated MAT at discharge is the most common avoidable gap.
— Phone call or telehealth within 48–72 hours for medication reconciliation, symptom check, AUD support
— In-person visit within 7–14 days with PCP or hepatology
— Hepatology every 3 months for decompensated disease, every 6 months for compensated cirrhosis
— Addiction medicine/psych weekly to biweekly during first 3 months
— CMP, INR, CBC at each visit
— MELD-Na recalculated at follow-up to track trajectory and transplant eligibility
— PEth every 3 months in transplant candidates or when objective verification needed; EtG for shorter windows
— LFTs improving substantially within 4–8 weeks of abstinence is a reliable prognostic sign
— Brief intervention (FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) at every PCP visit
— Motivational interviewing, cognitive-behavioral therapy, 12-step facilitation (AA), SMART Recovery, contingency management
— Intensive outpatient programs (IOP) 9–20 hours/week; partial hospitalization for higher acuity
— Residential rehab for severe AUD without stable housing
— Treat co-occurring depression, anxiety, PTSD aggressively; SSRIs preferred (avoid sedating agents)
— Dietitian referral; target 35 kcal/kg, 1.2–1.5 g/kg protein; late evening snack
— Physical therapy for sarcopenia; supervised exercise improves muscle mass and HE risk
— Vitamin D repletion; calcium 1200 mg/day
— Frame relapse as a chronic disease event, not failure; reassess pharmacotherapy adherence, dose, regimen switch
— Re-engage in higher level of care; harm-reduction counseling if abstinence not yet achievable
Board pearl: Improvement in MELD by ≥3 points and bilirubin by ≥25% in the first 30 days of abstinence is a strong favorable prognostic indicator; failure to improve at 90 days of true abstinence pushes transplant evaluation forward.
— Historical 6-month abstinence requirement is no longer universally required; current practice individualizes based on psychosocial risk assessment
— Selection cannot legally or ethically discriminate solely on AUD; equal consideration is the standard
— Informed consent for transplant must include lifelong abstinence expectation, monitoring with PEth/EtG, and consequences of relapse
— Encephalopathic patients may lack capacity; reassess after lactulose, infection treatment, electrolyte correction
— Acute intoxication does not equal lack of capacity for all decisions — assess per-decision; severe intoxication or withdrawal usually warrants surrogate involvement for major decisions
— Document capacity assessment with the four elements: understanding, appreciation, reasoning, expressing a choice
— Federal regulation provides heightened protection for substance use disorder records; written consent required for most disclosures, more stringent than HIPAA
— Implications for care coordination: obtain explicit consent for sharing with family, employers, courts
— Suspected child abuse/neglect in households with active AUD — clinician is a mandated reporter
— Impaired driving: state-specific (some require physician reporting of medically unfit drivers); counsel against driving with HE
— Suspected elder abuse
— Healthcare professionals with AUD: physician health programs offer confidential treatment alternatives to licensure action
— Commercial drivers, pilots: DOT/FAA regulations require reporting and abstinence verification
— Highest-risk window for relapse, withdrawal recurrence, missed paracentesis, medication errors
— Discharge bundle: medication reconciliation, scheduled follow-up within 7 days, clear written instructions, Naloxone if co-occurring opioid use, "teach-back" with patient/family
— ACLF grade 3 with multiple organ failures and no transplant option: align goals of care, involve palliative team, time-limited trials
Step 3 management: When transferring an ALD patient to an outside SUD treatment facility, you need a 42 CFR Part 2-compliant written authorization — a standard HIPAA release is not sufficient, and unauthorized disclosure can trigger federal penalties.
— AST:ALT ≥2 with both <300 → alcohol
— MDF ≥32 or MELD ≥20 → severe AH, consider steroids
— Lille ≥0.45 at day 7 → steroid nonresponder, stop steroids
— Child-Pugh C ≥10 points → decompensated, ~50% 1-yr mortality
— MELD ≥15 → transplant listing threshold
— SAAG ≥1.1 = portal HTN; <1.1 = peritoneal/malignant/TB
— Ascitic PMN ≥250 = SBP
— HVPG ≥10 = clinically significant portal HTN, ≥12 = variceal bleed risk
— Hb transfusion target ~7 g/dL in variceal bleed
— Naltrexone — avoid acute hepatitis, avoid with opioids
— Acamprosate — renal dose-adjust
— Disulfiram — needs motivated patient, no cirrhosis, no cardiac disease
— Baclofen — safest in decompensated cirrhosis
— Lorazepam/oxazepam/temazepam — safer benzos in liver disease
— Carvedilol — preferred NSBB for varices
— Terlipressin — FDA-approved for HRS-AKI (since 2022)
— Rifaximin + lactulose — recurrent HE
— Thiamine before glucose (always) to prevent Wernicke
— Refeeding syndrome: monitor phosphate, magnesium, potassium
— Hypoglycemia common in advanced liver disease — depleted glycogen
— Alcohol is Group 1 carcinogen: oral, pharyngeal, laryngeal, esophageal SCC, breast, colorectal, liver
— STOPAH: pentoxifylline no benefit; prednisolone short-term benefit only
— COMBINE: naltrexone + medical management effective; acamprosate alone not superior to placebo in US population
Board pearl: "Thiamine before glucose" applies to every alcohol-use patient receiving IV fluids in the ED — give 100 mg IV thiamine first; failure to do so before a D5 infusion is a classic distractor-and-trap question stem.
— 45-year-old man with daily heavy drinking presents with 3 weeks of jaundice, tender hepatomegaly, AST 180, ALT 70, bilirubin 12, INR 1.9, WBC 16k. Calculate MDF; if ≥32, next step after ruling out infection (paracentesis, blood cultures, CXR) is prednisolone 40 mg daily; reassess with Lille day 7.
— Patient admitted for pancreatitis, day 2 develops tremor, HR 120, BP 165/95, hallucinations. Next step: symptom-triggered lorazepam via CIWA-Ar protocol + thiamine 100 mg IV + folate + multivitamin; do NOT use chlordiazepoxide if liver disease.
— Patient with compensated cirrhosis (Child-Pugh A) and AUD asks about medications to stay sober. Acamprosate or baclofen preferred over naltrexone in significant liver disease; disulfiram contraindicated.
— Same patient with CrCl 25: acamprosate contraindicated → baclofen.
— Cirrhotic with fever, abdominal pain, confusion, ascitic PMN 450. Diagnostic paracentesis → SBP → ceftriaxone 2 g IV + albumin 1.5 g/kg day 1, 1 g/kg day 3. Discharge with daily ciprofloxacin prophylaxis.
— Patient with chronic alcohol use, normal exam, mildly elevated LFTs. Calculate FIB-4 and APRI; if elevated, order transient elastography (FibroScan).
— Patient stabilized after severe AH ready for discharge. Initiate MAT (acamprosate), refer to IOP/AA, schedule hepatology in 2 weeks, vaccinate HAV/HBV/pneumococcal, start NSBB if varices, lactulose if HE, thiamine + folate.
— Pregnant patient at 12 weeks screens AUDIT-C positive. Brief intervention + close follow-up + social work; admit if withdrawal risk.
Step 3 management: When the stem ends with "what is the next best step?" in suspected severe AH, the answer is almost always rule out infection with paracentesis + blood/urine cultures + CXR before starting prednisolone — not the steroid itself.
Alcohol-associated liver disease is best managed by pairing complete abstinence (supported by AUD pharmacotherapy and behavioral treatment) with stage-specific care — nutrition and vaccination for steatosis, prednisolone with Lille-guided continuation for severe alcohol-associated hepatitis (MDF ≥32 or MELD ≥20) after ruling out infection, decompensation management (lactulose/rifaximin, NSBB, paracentesis with albumin, SBP prophylaxis) for cirrhosis, and timely transplant referral for nonresponders and MELD ≥15 candidates.
— Diagnose: AST:ALT ≥2 with both <300, macrocytosis, elevated GGT; rule out viral/autoimmune/metabolic causes; risk-stratify with MDF, MELD-Na, Child-Pugh, FIB-4, FibroScan
— Treat AH: Rule out infection → prednisolone 40 mg × 28 days → Lille day 7; stop steroids if nonresponder and refer for early transplant
— Treat AUD: Naltrexone (avoid acute hepatitis), acamprosate (avoid CKD), baclofen (safest in cirrhosis), disulfiram (motivated only); pair with AA/IOP/CBT; start before discharge
— Prevent complications: Lactulose ± rifaximin for HE; carvedilol or banding for varices; albumin with paracentesis ≥5 L and with SBP; HCC surveillance US every 6 months; vaccinate HAV/HBV/pneumococcal/flu/COVID
— Special populations: Thiamine before glucose, always; lorazepam/oxazepam in liver disease; APAP ≤2 g/day, avoid NSAIDs; pregnancy = zero alcohol
— Follow-up: Phone within 72 hours, visit within 7–14 days, PEth every 3 months in transplant candidates, MELD trended at every visit, 42 CFR Part 2 consent for SUD record sharing
Board pearl: The single most outcome-modifying intervention across every stage of ALD is sustained abstinence — pharmacotherapy and counseling exist to achieve it, and every Step 3 management answer that pairs MAT + behavioral support + hepatology follow-up at discharge will be correct.