Alcohol-Related Liver Disease (ArLD)

Alcohol-related liver disease is one of the commonest causes of liver admissions in the NHS.
Patients often present late, with complex medical, psychological, and social needs.

This guide focuses on how doctors should recognise and manage ArLD on the ward and on-call.

What is alcohol-related liver disease?

ArLD is a spectrum of liver injury caused by alcohol, ranging from reversible early disease to advanced irreversible cirrhosis.

It includes:

  • Fatty liver (steatosis)
  • Alcoholic hepatitis
  • Fibrosis and cirrhosis
  • Decompensated liver disease

In simple terms:

Ongoing alcohol exposure progressively damages the liver until it can no longer function.

How does it present?

Patients may present in many ways.

Common presentations:

  • Jaundice
  • Ascites
  • Peripheral oedema
  • Abdominal distension
  • Confusion (encephalopathy)
  • GI bleeding
  • Weight loss
  • Recurrent admissions with “generally unwell” picture

Sometimes the only clue is:

  • Raised LFTs
  • Macrocytosis (high MCV)
  • Low platelets

Common patterns you will see on blood tests

Typical features in ArLD:

  • AST > ALT (often ratio >2:1)
  • Raised bilirubin
  • Raised ALP
  • Low albumin (in advanced disease)
  • Raised INR (in advanced disease)
  • Low platelets (portal hypertension)

These patterns suggest chronic liver injury, not just “abnormal LFTs”.

On the ward, always ask

How much alcohol is this patient actually drinking?

And ask it properly:

  • What type of alcohol?
  • How much per day/week?
  • How long have they been drinking at this level?
  • When was their last drink?

Underestimating intake = underestimating risk.

First priority = assess severity and complications

Do not focus only on alcohol history.
Assess for complications of liver disease:

Look for:

  • Ascites
  • Encephalopathy
  • GI bleeding
  • Infection
  • AKI
  • Hyponatraemia
  • Malnutrition

Patients often deteriorate because complications are missed, not because alcohol is missed.

Immediate management on the ward (what juniors should actually do)

If reviewing a patient with suspected ArLD:

Do early:

  • A–E assessment
  • Bloods: FBC, U&E, LFTs, INR, CRP
  • Clotting and albumin to assess synthetic function
  • Infection screen if unwell
  • Abdominal ultrasound (if not recently done)

Practical steps:

  • Treat complications (ascites, HE, SBP, AKI etc.)
  • Avoid hepatotoxic drugs
  • Correct electrolytes
  • Early nutrition input (very important)
  • Give thiamine (IV if inpatient at risk)
  • Assess for alcohol withdrawal risk

Never forget thiamine — Wernicke’s is preventable.

Alcoholic hepatitis (important subgroup)

Some patients present with:

  • Marked jaundice
  • Fever
  • Tender hepatomegaly
  • Very high bilirubin
  • Raised INR
  • Systemically unwell

This may represent severe alcoholic hepatitis, which has high mortality and needs:

  • Urgent senior review
  • Consideration of steroids (specialist decision)
  • MDT input

Do not dismiss this as “just liver disease”.

When to escalate

Escalate early if:

  • New jaundice with systemic illness
  • Encephalopathy
  • Rising INR
  • AKI
  • Sepsis
  • GI bleed
  • NEWS ≥5
  • Concern from nursing staff

These patients often need:

  • Gastro/hepatology input
  • HDU/ICU review
  • MDT discussion

Common mistakes juniors make

  • Focusing only on alcohol history and missing complications
  • Forgetting thiamine
  • Not assessing withdrawal risk
  • Assuming jaundice is “chronic and stable”
  • Not involving alcohol services early
  • Delayed escalation in severe alcoholic hepatitis

Take-home concept

Alcohol-related liver disease is not just about alcohol.
It is about recognising complications early, treating them properly, and supporting long-term change.