Intended for healthcare professionals

Clinical Review

Decompensated alcohol related liver disease: acute management

BMJ 2016; 352 doi: (Published 26 January 2016) Cite this as: BMJ 2016;352:i124
  1. Stuart McPherson, consultant hepatologist1 2,
  2. Michael R Lucey, professor of hepatology3,
  3. Kieran J Moriarty, consultant gastroenterologist4
  1. 1Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  2. 2Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
  3. 3Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
  4. 4Department of Gastroenterology, Royal Bolton Hospital, Bolton, UK
  1. Correspondence to: S McPherson, Liver Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK stuart.mcpherson{at}

What you need to know

  • Decompensated alcohol related liver disease (ARLD) occurs when there is a deterioration in liver function in a patient with cirrhosis, which presents with jaundice, coagulopathy, ascites, and hepatic encephalopathy

  • The short term mortality rate from decompensated ARLD is high (10-20% at one month)

  • Early aggressive treatment of infections, alcohol related hepatitis, acute kidney injury, gastrointestinal bleeding, and encephalopathy can improve survival in patients with decompensated ARLD

  • All patients admitted with ascites should have a diagnostic tap, since “silent” spontaneous bacterial peritonitis is common. A diagnostic tap can be performed in patients with coagulopathy

  • Every effort must be made to help patients with an episode of hepatic decompensation to achieve long term abstinence, otherwise the prognosis is poor

  • Acute hospitals should establish a consultant led, multidisciplinary alcohol care team

Alcohol related liver disease (ARLD) and liver cirrhosis are complications of long term excessive alcohol use and occur in 10-20% of chronic, heavy drinkers.1 2 Complications, including hepatic decompensation, variceal bleeding, and hepatocellular carcinoma, reduce life expectancy.1 3 Since 1970, there has been a 400% increase in liver related (mainly alcohol related) deaths across all ages in the UK (fig 1).4 5 Liver disease is now the fifth commonest cause of death in the UK. The average age of death from ARLD is 59 years.6

Fig 1 Standardised mortality data for major causes of death in UK, 1970-2010. Reproduced with permission of Nick Sheron

In a report of UK hospitals only 47% of patients received “good” hospital care.7 This review provides guidance on the management of patients with decompensated ARLD, focusing on the first 24 hours after hospital admission.

What is decompensated ARLD?

Figure 2 provides a summary of the clinical course of ARLD. Decompensation of cirrhosis occurs when liver function deteriorates, and the disease presents with jaundice …

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