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Treatment strategies for ALD include lifestyle changes to reduce alcohol consumption, cigarette smoking, and obesity; nutrition therapy; pharmacological therapy; and possibly liver transplantation.

Lifestyle Changes

Abstinence from alcohol is vital in order to prevent further liver injury, scarring, and possibly liver carcinoma; it appears to benefit patients at every stage of the disease. Fatty liver is reversible with abstinence. Although evaluations of the effects of abstinence on the progression of ALD are few and have involved retrospective, nonrandomized trials, virtually all these studies have shown beneficial effects of abstinence. Patients with either compensated or decompensated cirrhosis benefit from abstinence. Thus, all patients with ALD should be encouraged to abstain from alcohol consumption. Newer medications to facilitate abstinence, such as naltrexone and acamprosate, have been shown to be effective in some chronic alcoholics, but no large multicenter studies have evaluated these medications in patients with ALD.

Many people who drink alcohol also smoke cigarettes. In European studies, fibrosis worsens more rapidly in ALD patients who smoke cigarettes. Patients with hepatitis C who drink also deteriorate faster if they smoke cigarettes. Cigarette smoking causes oxidative stress, a condition that arises when an overabundance of free radicals is present in the body, which may be a factor leading to accelerated liver disease in smokers.

Obesity is associated with the development of fatty liver and nonalcoholic steatohepatitis, a disorder that is histologically identical to alcoholic hepatitis. Body mass index has been shown to be an independent risk factor for the development of ALD. An increasingly large subset of ALD patients are obese, with alcohol intake as a source of excess and empty calories. Thus, as with many other gastrointestinal disorders (gastroesophageal reflux disease), the initial approach to treating ALD is lifestyle modification to reduce alcohol consumption, cigarette smoking, and obesity.

Nutrition Therapy

Malnutrition is prevalent in alcoholic hepatitis and cirrhosis, especially in end-stage ALD, and can range from deficiency in individual nutrients to global protein-calorie malnutrition.

Researchers at the VA Cooperative Studies Program have conducted some of the most extensive studies of nutritional status in patients with alcoholic hepatitis. The first of these studies demonstrated that virtually every patient with alcoholic hepatitis had some degree of malnutrition. Patients had an average alcohol consumption of 228 grams per day, with almost 50 percent of energy intake coming from alcohol. The severity of liver disease generally correlated with the severity of malnutrition.

A followup VA study on alcoholic hepatitis found similar results. In both of these studies, patients were given a balanced 2,500-kilocalorie hospital diet, monitored carefully by a dietitian, and were encouraged to follow it. In the second study, patients in the treatment group also received a liquid nutritional supplement high in three amino acids that help to stimulate protein synthesis (which was administered as an oral food supplement), as well as the anabolic steroid oxandrolone. In neither study were patients fed by tube if voluntary oral intake was inadequate (probably a design flaw, in retrospect). Voluntary oral food intake correlated in a stepwise fashion with 6-month mortality data - that is, almost all patients who voluntarily consumed more than 3,000 kcal per day still were living at the end of the 6-month period, whereas more than 80 percent of those consuming less than 1,000 kcal per day died within that time. Moreover, the degree of malnutrition correlated with the development of serious complications such as encephalopathy, ascites, and hepatorenal syndrome.

Interest in nutrition therapy for cirrhosis was stimulated when Patek and colleagues demonstrated that a nutritious diet improved the 5-year outcome of patients with alcoholic cirrhosis compared with patients consuming an inadequate diet. Several recent studies have found improved outcomes in cirrhosis patients who were given nutritional support. Hirsch and colleagues demonstrated that outpatients receiving a nutritional support products through a feeding tube had significantly improved protein intake and significantly fewer hospitalizations. These investigators subsequently gave enteral nutritional support to outpatients with alcoholic cirrhosis and observed an improvement in nutritional status and immune function.

VA Cooperative Study 275 found that the combination of an anabolic steroid and an oral nutritional supplement reduced the mortality rate of patients who had moderate protein-energy malnutrition. Those with severe malnutrition did not significantly benefit from the therapy, possibly because their malnutrition was so advanced that no intervention, including nutrition, could help.

Kearns and colleagues showed that patients with ALD who were hospitalized for treatment and given an enteral nutritional supplement via tube feeding had significantly improved serum bilirubin levels and liver function. Moreover, a major randomized study of enteral nutrition versus steroids in patients with alcoholic hepatitis showed similar overall initial outcomes, as well as fewer long-term infections in the nutrition group. This important study suggests that aggressive nutritional support is as effective as treatment with prednisone (an immunosuppressive medication), with its potential complications (infections, diabetes, osteoporosis), in hospitalized patients with alcoholic hepatitis.

Thus, traditional nutritional supplementation clearly improves nutritional status and, in some instances, hepatic function and other outcome indicators in alcoholic hepatitis and cirrhosis.

Tags: Alcoholism

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