Excessive alcohol consumption is a global healthcare problem as it causes the greatest degree of tissue injury in the liver because it is the primary site of ethanol metabolism. Chronic excessive alcohol consumption leads to a wide variety of hepatic lesions, mainly steatosis, hepatitis, and fibrosis/cirrhosis. 

The earliest response to heavy drinking is Steatosis, characterized by the deposition of fat in hepatocytes. Steatosis can further progress to a more severe, inflammatory type of liver injury known as steatohepatitis. Steatohepatitis can cause fibrosis, which leads to excessive deposition of extracellular matrix proteins. The fibrotic response includes active pericellular fibrosis, which may advance to cirrhosis, featuring excessive liver scarring, vascular alterations, and eventual liver failure. 

Current Management of ALD

No FDA-approved therapy exists for treating patients with ALD, with current therapies utilized only for optimal ALD management.

Abstinence

Drinking cessation comes as the best and the most effective therapy in patients with ALD. It not only helps resolve alcoholic steatosis but also improves survival in cirrhotic patients. Its effect can be further enhanced with the combination of lifestyle modifications (e.g., behavioural interventions and dietary alterations).

Natural and Artificial Steroids

Corticosteroid treatment, as with prednisolone, is mostly used for moderate to severe alcoholic hepatitis, to suppress the immune response and proinflammatory cytokine response. European Association for the Study of the Liver 2012 suggests discontinuation of therapy if it doesnt show any decrease in bilirubin levels by day 7 of treatment.

Nutritional Supplements

Severe alcoholic hepatitis and cirrhosis are often accompanied by malnourishment, which further correlates with disease severity and complications, like variceal bleeding, ascites, infections, encephalopathy, and hepatorenal syndrome. 

ALD shows deficiencies in micronutrients e.g., folate, vitamin B6, vitamin A, and thiamine; and minerals e.g., selenium, zinc, copper, and magnesium; which may be involved in its pathogenesis. 

The current guidelines of the American Association for the Study of Liver Diseases recommend assessing all patients with alcoholic hepatitis or advanced ALD for nutritional deficiencies and treating aggressively with enteral nutritional therapy. 

A protein intake of 1.5 grams/kg body weight and 35-49 kcal/ kg body weight/ day is recommended for ALD patients. 

Mechanistic studies on micronutrient supplementation have shown that they render protection by blocking or attenuating most mechanisms of liver injury, including increased gut permeability, oxidative stress, increased TNF production, and hepatocyte apoptosis. Zinc supplementation has also proven to be an effective therapeutic approach as the liver function of ALD and HCV patients improve with 50 mg of elemental zinc.

Liver Transplantation

Liver transplantation is seen as the standard of care for patients with end-stage liver disease. Some patients with ALD can’t be a candidate for orthotopic liver transplantation because of continued alcohol consumption, improvement in liver function after abstinence, and a higher incidence of cancers of the upper airways and upper digestive tract. Thus it is necessary to screen them for common malignancies and evaluate for medical and psychiatric conditions. <20 percent of patients with the primary cause of end-stage liver disease as alcohol, receive liver transplants. But the patient and organ survival remains excellent with good improvement in their quality of life. 

Since a majority of the transplant recipients indulge in alcoholism again afterwards, post-transplant interventions are extremely valuable in supporting patients to maintain abstinence.

Unconventional and Herbal Remedies

Natural and herbal therapies due to their potential for hepatoprotection also remain popular among patients with liver diseases. 

An extract of milk-thistle seeds (silymarin) and garlic see extreme popularity, followed by ginseng, green tea, gingko, echinacea, and St. John’s wort. Other natural medicines like betaine, curcumin, fenugreek seed polyphenol, LIV-52, vitamin E, and vitamin C, have also shown efficacy in experimental models of alcoholic liver injury but still warrants large randomized, controlled clinical trials.

Source: Osna NA, Donohue TM Jr, Kharbanda KK. Alcoholic Liver Disease: Pathogenesis and Current Management. Alcohol Res. 2017;38(2):147-161.