Lifestyle Changes

Establishing and maintaining abstinence from alcohol is vital in order to prevent further ongoing liver injury, fibrosis, and, possibly, hepatocellular carcinoma. Abstinence allows total resolution of alcoholic steatosis. There are limited studies evaluating the effects of abstinence from alcohol on the progression of ALD, but virtually all of them show beneficial effects on survival. Moreover, data from recent Veterans Health Administration (VA) cooperative studies suggest that reducing, but not stopping, ethanol consumption also improves projected survival in ALD. The so-called "brief interventions" are the simplest form of psychological therapy for alcohol abuse and can be implemented by nonpsy-chiatric staff. These interventions involve educating and informing patients regarding the nature of their problem and providing them with advice as to how to change their behavior. Thus, abstinence, or a major reduction in drinking, should be encouraged in all patients with ALD. Newer agents to improve abstinence, such as Naltrexone and Acamprosate, have been shown to be effective in some chronic alcoholics; however, there are no large multicenter studies evaluating these drugs in patients with ALD. There is a separate chapter on alcoholism (Chapter 37).

Many subjects who drink alcohol also smoke cigarettes. Smoking cigarettes has been shown in European studies to increase the rate of progression of fibrosis in ALD. Moreover, hepatitis C (HC) patients who drink also have accelerated disease progression if they smoke cigarettes. Cigarette smoking causes oxidative stress, which may be the underlying mechanism for the observed accelerated liver disease in smokers.

Obesity is associated with the development of fatty liver and nonalcoholic steatohepatitis. Body mass index has been shown to be an independent risk factor for the development of ALD. Thus, the initial approach to ALD is lifestyle

TABLE 115-2. Therapy for Alcoholic Liver Disease

• Lifestyle modification (alcohol cessation, smoking, obesity)

• Proper nutrition/nutrition support

• Consider pentoxifylline or prednisone for alcoholic hepatitis

• Consider silymarin or SAMe for cirrhosis

• Correct metabolic disturbances/complications

• Transplantation in selected abstinent patients with end-stage liver disease SAMe = S-adenosylmethionine.

modification related to issues of alcohol consumption, cigarette smoking, and obesity.

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