1. Liver function tests and ultrasound examination should be conducted among patients with harmful alcohol use and/or alcoholic use disorder (AUD).
2. Liver biopsy is not routinely advisable for diagnosis of alcoholic fatty liver disease. Nonetheless, liver biopsy and non-invasive tools of fibrosis may be considered for diagnosis of steatohepatitis and/or liver fibrosis.
3. The Alcohol Use Disorders Inventory Test (AUDIT) is a validated tool for diagnosis of patients with alcohol abuse and dependence.
4. Alcohol consumption is a major cause of disease progression and long-term outcome of patients with ALD. Complete abstinence from alcohol consumption is the key approach for the management of every spectrum of ALD.
5. Multidisciplinary teams including alcohol addiction specialists should be ideally used for the medical treatment of ALD.
6. Alcohol withdrawal syndrome (AWS) should be stratified and managed as per Clinical Institute Withdrawal Assessment for Alcohol protocol.
7. Benzodiazepines are the treatment of choice in patients with severe AWS and ALD.
8. Clinical diagnosis of AH is evaluated in a patient with rapid development or exacerbation of jaundice and liver-related complications, with serum total bilirubin >3 mg/dL; ALT and AST elevated >1.5 times the upper limit of normal but <400 U/L with the AST/ALT ratio >1.5; record of persistent heavy alcohol use until 8 weeks before onset of symptoms; and exclusion of other liver diseases.
9. A transjugular liver biopsy is recommended when the clinical diagnosis is confounded by another liver disease etiology or there is uncertainty on alcohol consumption history in patients with suspected AH.
10. Patients with severe AH should preferably be hospitalized for management.
11. Severe AH is diagnosed by Maddrey’s discriminant function score >32 or MELD score >20.
12. Systemic inflammatory response syndrome (SIRS) syndrome at admission influences acute kidney injury and multi-organ failure, which are correlated to a poor prognosis. Physicians should take appropriate methods to prevent renal injury, including avoidance of nephrotoxic drugs, judicious use of diuretics, and low threshold for expanding circulating blood volume with albumin or saline infusions.
13. Infections are common in AH patients and a comprehensive infectious screening should be conducted as part of routine work-up of these patients. The development of bacterial infections during hospitalization is linked to poor prognosis.
14. Response to treatment with corticosteroids should be assessed at 7 days using the Lille score. Management should be discontinued among non-responders to therapy, defined as those with a Lille score >0.45.
15. Patients non-responsive to corticosteroids, disqualified for early LT, and with multiple organ failures may be considered for palliative therapy.
16. Physicians should consider LT while framing a management plan for patients with end-stage ALD.
17. The decision on LT assessment should not be dependent solely on minimum 6 months of alcohol abstinence, and other criteria should be taken into consideration.
18. Patients too sick to complete rehabilitation therapy may be evaluated for transplantation via exception pathway dependent on individual center policy and the patient’s profile. These patients should complete rehabilitation therapy after transplantation.
19. Transplant recipients should be screened at each visit for use of alcohol and other substances particularly tobacco and cannabis. Among recidivists, alcohol use should be measured to identify harmful use.
20. Immunosuppression should be optimized to use the lowest possible dose needed to prevent graft rejection. Use of sirolimus or everolimus should be preferred over other immunosuppression drugs.

Source: Singal AK, Bataller R, Ahn J, Kamath PS, Shah VH. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol. 2018;113(2):175-194.