22nd July 2023

Assessment and diagnosis

Taking a thorough alcohol history is key when there is a suspicion of ALD. There are a number of validated tools to screen for alcohol misuse, such as AUDIT, which consists of 10 questions. A link to the AUDIT tool can be found in the References section.

Clinical features

ALD may be asymptomatic or may present with a variety of symptoms, including fatigue, weight loss, anorexia, abdominal discomfort or distension, fever, nausea, vomiting and jaundice.

Findings on examination may be in keeping with chronic liver disease or excess alcohol intake, such as palmar erythema, Dupuytren’s contracture and parotid gland enlargement.

Investigations

Initial investigations should include a full set of liver biochemistry tests (AST, ALT, ALP, GGT, bilirubin and albumin)  – i.e. LFTs. AST is often the most raised, and more so than ALT. However, the transaminases can be normal in some people with severe ALD or even cirrhosis, so normal LFTs do not rule out the diagnosis.

Further basic blood tests include an FBC to assess for anaemia and thrombocytopenia, U&Es with magnesium and phosphate levels, and a coagulation screen.

Additional tests may be appropriate to exclude alternative causes of liver dysfunction; for example, a viral hepatitis screen, iron studies and auto-antibodies. This is also known as a ‘non-invasive liver screen’ (NILS).

Ultrasound is the first line imaging investigation, as a non-invasive and cheap way of assessing for pathological markers such as steatosis, and to exclude other pathology, e.g., gallstone disease.

Transient elastography is better for imaging the liver if there is a suspicion of severe fibrosis and cirrhosis, and should be offered to those with a history of chronic and heavy alcohol use. CT and MRI scans may show evidence of liver disease, but are not able to determine aetiology, and offer little additional extra information compared to ultrasound and elastography, so are generally not indicated.

Liver biopsy can be used to help determine the cause of the liver disease but is not necessary in every patient.

Further screening

Hepatocellular carcinoma (HCC) is an important potential complication of ALD. If suspected, α-fetoprotein (AFP) should be measured, as a serum marker strongly associated with HCC. First line imaging remains ultrasound, but CT or MRI may be needed as further investigations if HCC is suspected.

In addition to assessment of the liver, it is important to screen for other alcohol-related organ damage, for example, cardiomyopathy and chronic pancreatitis.

It is also important to include assessment of disease severity.

NICE recommends using the Model for End-Stage Liver Disease (MELD) score, the components of which consist of:

• Dialysis at least twice in the past week or continuous veno-venous haemodialysis for more than 24 hours
• Creatinine level
• Bilirubin level
• INR
• Sodium level

Another commonly used tool is the Child-Pugh score  – which uses bilirubin, albumin, INR, the presence of ascites and encephalopathy as its assessment metrics.