Alcohol-Related Liver Disease (ARLD)
NICE Clinical guideline [CG100] Alcohol-use disorders: diagnosis and management of physical complications. Last updated: Apr 2017.
Background information has been added accordingly.
Date: 10/11/25
Background Information
Definition
ARLD is a spectrum of liver pathology resulting from chronic and excessive alcohol consumption, encompassing: [Ref]
- Alcoholic fatty liver (isolated steatosis) – reversible
- Alcoholic hepatitis (steatohepatitis) – potentially reversible
- Alcoholic cirrhosis – irreversible
It is important to understand ARLD as a disease spectrum. However, in clinical practice, patients often present with overlapping features, so precise categorisation within the spectrum is less important than assessing current severity and complications.
Pathophysiology
ARLD mainly results from 2 pathophysiological mechanisms [Ref]
- Steatosis (fatty liver)
- Alcohol metabolism increases NADH:NAD+ ratio → inhibits lipolysis and stimulates lipogenesis → triglycerides accumulate in hepatocytes
- Hepatitis
- Alcohol is metabolised to acetaldehyde (a toxic metabolite) → acetaldehyde causes oxidative stress and direct hepatocyte injury → activates Kupffer cells → release of inflammatory cytokines
Chronic inflammation in the liver activates stellate cells → fibrosis → irreversible cirrhosis
Diagnosis
Although NICE does not provide a formal diagnostic checklist for ARLD, the diagnosis is generally based on the following points (supported by international guidelines and the wider literature): [Ref]
- History of prolonged and excessive alcohol intake
- Clinical features consistent with ARLD
- Characteristic laboratory findings
- Exclusion of alternative causes of liver disease / jaundice
- Mechanical obstruction: HCC, biliary obstruction, Budd-Chiari syndrome
- Viral hepatitis
- Autoimmune hepatitis
- Drug-induced liver injury
- Ischaemic hepatitis
Clinical Features
Features that are more suggestive of ARLD (as opposed to general chronic liver disease):
- History of heavy alcohol use – one of the most important factors
- Parotid gland enlargement (alcoholic sialadenosis)
- Dupuytren’s contracture
- Temporal muscle wasting
- Peripheral neuropathy (due to vitamin B deficiency)
- Sarcopenia (muscle wasting but relatively preserved fat) (due to protein-calorie malnutrition)
Most other clinical features are non-specific and can be seen in any cause of chronic liver disease:
| Compensated chronic liver disease | Patients are often asymptomatic
Signs:
|
| Decompensated chronic liver disease |
|
ARLD may also present as acute alcoholic hepatitis, patient typically presents with
- Jaundice
- Fever
- RUQ pain
- Tender hepatomegaly
Biochemical Changes
Biochemical changes in ARLD: [Ref]
- ↑ AST and ALT (but <400 IU/L – i.e. not markedly raised)
- AST:ALT ratio >2
- But AST and ALT levels should NOT be markedly raised (< 400 IU/L) (higher than 400 IU/L should raise concern of other causes)
- ↑ GGT
- Macrocytosis / macrocytic anaemia
Biochemical changes due to impaired liver synthetic function: [Ref]
- ↑ Bilirubin
- ↑ PT / INR
- ↓ Albumin
- ↓ Platelet
Imaging
Imaging is NOT used to diagnose ARLD. The diagnosis is largely clinical. The role of imaging is mainly to 1) exclude differential diagnoses, 2) assess the stage of liver disease and 3) identify complications.
Choice of imaging:
- 1st line: ultrasound
- 2nd line: CT
Definitive Test
Definitive test: transjugular liver biopsy
- It is NOT performed routinely, only reserved for cases when diagnosis is uncertain / atypical presentation / atypical laboratory tests / high suspicion of autoimmune hepatitis
- Liver biopsy is associated with a significant risk of morbidity and mortality
Testing for Cirrhosis
NICE recommends using transient elastography (e.g. FibroScan) to check for cirrhosis in patients with ARLD
See the Cirrhosis article for further information.
Management
Long-Term Management
There is no specific treatment for ARLD, apart from providing general / conservative advice and care:
- Alcohol abstinence (see the Alcohol Use Disorders article) – most important
- Offer oral thiamine (as patients with ARLD are often thiamine-deficient and at risk of Wernicke’s encephalopathy)
- Offer hepatitis A and B immunisations (to be offered to those with chronic liver disease)
- Assess nutritional intake and offer support if needed
- Lifestyle advice (e.g. weight reduction, smoking cessation)
- Optimise other comorbidities (e.g. obesity, diabetes, hypertension)
Alcoholic Hepatitis Management
Apart from supportive care, corticosteroids can be offered to those with severe alcoholic hepatitis (defined as discriminant function ≥32)
Recent US guidelines (ACG 2024) support the use of IV N-acetylcysteine in combination with corticosteroids for patients with severe alcohol hepatitis. This recommendation is based on meta-analyses and trials showing a reduction in short-term mortality and early complications (e.g. infection and hepatorenal syndrome)
However, this is yet to be incorporated in UK guidelines.