Guidelines for the diagnosis and treatment of alcoholic liver disease (revised 2010)

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Fatty liver and alcoholic liver disease group, Chinese society of Hepatology, Chinese Medical AssociationKey words: liver disease, alcoholic


Fatty liver and alcoholic liver disease group, Chinese society of Hepatology, Chinese Medical Association

Key words: liver disease, alcoholic; diagnosis; treatment; guideline


[Keywords] Liverdisease, alcoholic; Diagnosis; Therapy; Guidebooks[Publicationtype]

Correspondingauthor:LIYou-ming,, theFirstAffiliatedHospital, CollegeofMedicine, ZhejiangUniversity.Hangzhou310003, China

Alcoholic liver disease is caused by chronic alcohol consumption. In the early stage, fatty liver is usually developed, which can develop into alcoholic hepatitis, liver fibrosis and cirrhosis. Severe alcoholism can induce a wide range of liver cell necrosis, and even liver failure. Alcoholic liver disease is one of the most common liver diseases in our country, which is harmful to people's health. To further standardize the diagnosis and treatment of alcoholic liver disease, Hepatology fatty liver and alcoholic liver disease study group of Chinese Medical Association organized experts at home, on the basis of the latest domestic and foreign research results and the relevant treatment on consensus, revise and supplement on 2006 for "alcoholic liver disease diagnosis and treatment guidelines". This revision is mainly in accordance with the principle of evidence-based medicine, which based on the recommendation of the level of evidence is divided into 3 levels of 5 grades of [1], taking the Rome numbers in brackets in italics.

The "guide" to help clinicians to make correct decisions on the diagnosis and treatment of alcoholic liver disease, are not mandatory standards, clinicians in a specific patient, should be fully aware of the disease the best clinical evidence and the existing medical resources, and on the basis of comprehensive consideration of the patient's specific condition and intention, according to their own knowledge and experience, formulate reasonable treatment scheme.

First, epidemiology

Although there is still a lack of national epidemiological survey of alcoholic liver disease in China, the prevalence of alcohol drinking and alcoholic liver disease in China has been increasing. According to epidemiological survey of North China, from early 1980s to early 90s, the proportion of alcoholics in the general population from 0.21% to 14.3%[2]; the beginning of this century, the southern and western provinces according to epidemiological survey of drinking population increased to 30.9% ~ 43.4%[2-5] (III).

Drinking crowd some alcoholics or excessive drinking crowd health problems related to alcohol, including alcoholic liver disease is the most common organ damage caused by alcohol. At the beginning of this century, the epidemiological survey of alcoholic liver disease in the southern and western provinces showed that the prevalence of alcoholic liver disease in adults was 4.3% ~ 6.5%[3-5] (III). Alcoholic liver disease in hospitalized patients with liver disease accounted for the proportion of the rise, from 1991 4.2% to 1996 21.3%; alcoholic liver cirrhosis in the cause of liver cirrhosis ratio increased from 10.8% in 1999 to 24.0%[6-7] in 2003 (III). Alcohol induced liver injury has become a problem that cannot be ignored in china.

Two, risk factors

More influence the progression of alcoholic liver injury or aggravating factors, risk factors of research at home and abroad have been found mainly include: drinking, drinking, alcohol drinking, variety, sex, race, obesity, hepatitis virus infection, genetic factors, nutritional status.

According to the epidemiological survey data, alcohol induced liver injury is a threshold effect, that is to achieve a certain amount of alcohol consumption or drinking, will greatly increase the risk of liver damage [8]. However, because of the large individual differences, some studies have shown that the dose effect relationship between alcohol consumption and liver injury is not very clear [8-10].

There are many kinds of alcoholic beverages, and the damage to liver caused by different alcoholic beverages is also different ([11-12]). Alcohol consumption is also a risk factor for alcoholic liver injury, and fasting drinking is more likely to cause liver injury than [12].

Women are more sensitive to alcohol mediated hepatotoxicity, and may have a more severe alcoholic liver disease ([13]) when compared to men with lower doses and shorter duration of alcohol consumption. Drinking the same amount of alcoholic beverages, male and female blood alcohol levels were significantly different [14] (-2).

[15] (-2), genetic [16-17] (III) and individual differences in [8] (III) are also important risk factors for alcoholic liver disease. Han people in alcoholic liver disease susceptibility gene for alcohol dehydrogenase (ADH), 2 ADH3 (ALDH) and aldehyde dehydrogenase 2 allele frequency and genotype distribution is different from the western countries, the incidence may be Chinese people addicted to drinking and alcoholic liver disease rate is lower than in western countries, one of the reasons [16]. Not all drinkers will appear in alcoholic liver disease, occur only in a small part of the population in that same area between groups there are individual differences [8].

The mortality of alcoholic liver disease is associated with the degree of malnutrition ([18]). A lack of vitamin A or a decrease in vitamin E levels may also aggravate liver damage to [19] (III). A diet rich in polyunsaturated fatty acids may contribute to the progression of alcoholic liver disease, while saturated fatty acids play a protective role in alcoholic liver disease ([20]). Obesity or overweight may increase the risk of progression of alcoholic liver disease ([8]).

Synergistic effect of [21] hepatitis virus infection and alcohol on the liver damage as (III), the hepatitis virus infection based on alcohol, or in alcoholic liver disease based on the concurrent HBV or HCV infection, can accelerate the occurrence and development of liver disease.

Three, the clinical diagnostic criteria of alcoholic liver disease

1 have a long history of drinking, usually more than 5 years, equivalent to the amount of ethanol and the male is more than 40g/d, the female is more than 20g/d, or within 2 weeks of a large number of drinking history, equivalent amount of ethanol >80g/d[22] (III). However, attention should be paid to the influence of gender and genetic predisposition. Ethanol (g) conversion formula = alcohol consumption (M1) * ethanol content (%) * 0.8.

2 clinical symptoms are non-specific and may be asymptomatic or have right abdominal pain, loss of appetite, fatigue, weight loss, jaundice and so on; with the aggravation, can have neuropsychiatric symptoms and spider angioma, liver palm performance such as [22] (III).

3 serum aspartate aminotransferase (AST) (-2), alanine aminotransferase (ALT) (III), gamma glutamyltransferase (GGT) (2 -2), total bilirubin (TBil) (III), prothrombin time (PT), (III) the average red blood cell volume (MCV) (-2) and carbohydrate deficient transferrin (CDT) (-2 II) index increased [22-25]. Among them, AST/ALT>2, GGT increased, MCV increased as the characteristics of alcoholic liver disease, while the CDT determination was more specific, but it was not carried out in clinic. These indicators can be significantly reduced, usually within 4 weeks of normal return to normal (but slower GGT recovery) [26-27] (II -2), help to diagnose.

4 liver B ultrasound or CT examination has typical performance [28-31] (see "guide" imaging diagnosis part) (II -2).

5 excludes hepatotropic virus infection, drug and toxic liver injury and autoimmune liver disease such as [22] (III).

With first, 2, 3 and fifth or first, 2, 4 and fifth can be used for the diagnosis of alcoholic liver disease; with only first, suspected of alcoholic liver disease [22] 2 and fifth. In line with the first at the same time, there is evidence of viral hepatitis infection, diagnosis of alcoholic liver disease associated with viral hepatitis.

In accordance with the clinical diagnostic criteria of alcoholic liver disease, the clinical diagnosis is as follows.

1 cases of mild alcoholic liver disease: biochemical, imaging and histopathological examination of the liver were normal or slightly abnormal.

2 alcoholic fatty liver: imaging diagnosis in accordance with the criteria of fatty liver, serum ALT, AST or GGT can be slightly abnormal.

3 alcoholic hepatitis: short term massive hepatocellular necrosis caused by a group of clinical pathologic syndrome can occur in the foundation with or without cirrhosis, mainly for serum ALT, serum TBil and AST increased significantly, accompanied by fever, peripheral blood neutrophils. Severe alcoholic hepatitis refers to patients with alcoholic hepatitis liver failure, such as blood coagulation, jaundice, hepatic encephalopathy, acute renal failure, upper gastrointestinal bleeding, often accompanied by endotoxemia.

4 alcoholic cirrhosis: clinical manifestations and changes of serum biochemical markers in patients with cirrhosis.

Four, imaging diagnosis [28-31]

Imaging examination is used to reflect the distribution of fatty infiltration of the liver, roughly determine the degree of diffuse fatty liver, prompted the existence of liver cirrhosis, but it can not distinguish between simple fatty liver and fatty hepatitis, and difficult to detect 0.5 moderate; liver / spleen CT ratio is less than or equal to 0.5 degrees.

Five. Histopathological diagnosis [22]

Mixed fatty degeneration of liver cells in alcoholic liver disease were main pathological changes in bullous or bullous mainly associated with the vesicles. According to the pathological changes of liver tissue with inflammation and fibrosis, can be divided into simple fatty liver, alcoholic hepatitis, liver fibrosis and cirrhosis. The pathological diagnosis of alcoholic liver disease should include the degree of hepatic steatosis (F0 ~ 4), the degree of inflammation (G0 ~ 4), the grade of liver fibrosis (S0 ~ 4).

(a) simple fatty liver

According to the proportion of fatty liver cells in the liver tissue sections, according to the scope of the liver tissue samples obtained by the hepatic steatosis, the results were divided into 4 degrees (F0 ~ 4): F0

The degree of hepatic steatosis consistent with simple fatty liver, alcoholic hepatitis, divided into 4 degrees (F0 ~ 4), according to the degree of inflammation is divided into 4 levels (G0 ~ 4) G0 G1 3 with acinar inflammation; liver cells showed a few balloons, Intraacinar scattered in individual focal necrosis and central periphlebitis; G2 3 with obvious acinar ballooning hepatocytes, Intraacinar focal necrosis increased, Mallory body, mild to moderate portal tract inflammation; G3 3 with extensive acinar ballooning hepatocytes, Intraacinar focal necrosis, and apoptosis bodies appeared Mallory bodies, portal area with moderate inflammation and (or) around the portal tract inflammation; necrosis and fusion (or G4) bridging necrosis.

According to the scope and form of fibrosis, liver fibrosis is divided into 4 phases (S0 ~ 4): S0 S1 3 with no fibrosis; acinar focal or extensive perisinusoidal fibrosis and cell cycle / around central vein fibrosis; S2 fibrosis is extended to the portal area, around the central vein of sclerosing hyaline necrosis, focal or extensive portal tract stellate fibrosis; S3 acini extensive fibrosis, focal or extensive bridging fibrosis; liver cirrhosis S4.

The pathological diagnosis of alcoholic liver disease should include the degree of hepatic steatosis (F0 ~ 4), the degree of inflammation (G0 ~ 4), the grade of liver fibrosis (S0 ~ 4).

3 liver cirrhosis: the hepatic lobule structure was completely destroyed, the formation of false lobules and extensive fibrosis. According to whether there is an interface between the fiber hepatitis, divided into active and static.

Six, the treatment of alcoholic liver disease

(a) assessment method [32-34] (II -2)

There are several methods for evaluating the severity of alcoholic liver disease and the short-term survival rate, including Child-Pugh grade, prothrombin time - bilirubin discriminant function (Maddrey function) and model for end-stage liver disease (MELD) score, which has a high value of Maddrey discriminant function, the calculation formula is as follows: 4.6 * PT (s) difference +TBil (mg/d1).

(two) treatment

The principles of treatment for alcoholic liver disease are: abstinence from alcohol and nutritional support, reducing the severity of alcoholic liver disease, improving the presence of secondary malnutrition and symptomatic treatment of alcoholic cirrhosis and its complications [35-36].

1 abstinence: abstinence is the most important measure for the treatment of alcoholic liver disease ([37]).

2 nutritional support: alcoholic liver disease patients need good nutritional support, should be on the basis of alcohol to provide high protein, low fat diet, and pay attention to vitamin B, vitamin C, vitamin K and folic acid [38] (-2).

3 drug treatment: (1) glucocorticoid can improve the survival rate of patients with severe alcoholic hepatitis (with encephalopathy or Maddrey index >32). (2) the treatment of alcohol and alcohol can accelerate the elimination of alcohol from serum, which is helpful to improve the symptoms of alcoholism and abnormal behavior of [41]. (3) treatment of patients with alcoholic liver disease (S-) can improve the clinical symptoms and biochemical parameters of [42-43]. The tendency of polyene phosphatidylcholine to prevent the deterioration of histology in patients with alcoholic liver disease ([44-45]). Glycyrrhizin, silymarin, polyene phosphatidylcholine and glutathione drug has anti oxidant, anti-inflammatory, protect liver cell membrane and organelles in different degree, the clinical application can improve liver biochemistry index ([44, 46-47] II -2 II, -3). The treatment of alcoholic liver injury [48] (-2) can also be improved by the use of double cyclic alcohol. But not at the same time the application of various anti-inflammatory hepatoprotective drugs, so as not to aggravate the burden of the liver due to drug interactions and adverse reactions caused by (III). (4) liver fibrosis in patients with alcoholic liver disease is often accompanied by pathological changes of liver fibrosis. There are a variety of anti fibrosis medicine or prescription in the future should be based on the principle of evidence-based medicine, according to the standard of clinical research on new drugs (GCP) for the large sample, randomized, double-blind clinical trial, and the importance of liver histological examination results, to objectively evaluate the efficacy and safety of. (5) to deal with the complications such as portal hypertension, esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy and hepatocellular carcinoma ([37]). (6) patients with severe alcoholic liver cirrhosis may be considered for liver transplantation, but they are required to abstain from alcohol for a period of up to 6 months before liver transplantation, and there is no serious alcohol damage of other organs [49] (-2).

The main participants: Li Ming, Fan Jiangao, Wang Bingyuan, and so on, and so on, and so on, he, he, he, he, he, and so on, and so on, and so on, and so on, and so on, and so on,

The main revision: Ceng Minde, Jia Jidong, Yuan Pingge

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