How should I approach the management of a patient with cirrhosis due to alcohol, particularly regarding lifestyle modifications and pharmacotherapy?

Management of a patient with alcohol-related cirrhosis involves both lifestyle modifications and pharmacotherapy.

Lifestyle modifications: The cornerstone is complete abstinence from alcohol to prevent further liver damage and progression of cirrhosis. Patients should be offered support for alcohol cessation, including referral to specialist addiction services as appropriate. Nutritional assessment and support are essential, especially in cases of alcohol-related hepatitis, to address malnutrition and improve outcomes. Regular monitoring and surveillance for complications of cirrhosis, such as hepatocellular carcinoma (HCC) and oesophageal varices, should be implemented, including ultrasound every 6 months for HCC surveillance and upper gastrointestinal endoscopy to detect varices unless beta-blockers are planned for primary prevention ¹,².

Pharmacotherapy: For patients with severe alcohol-related hepatitis (discriminant function ≥32), corticosteroid treatment (e.g., prednisolone) may be offered after excluding active infection or gastrointestinal bleeding and managing renal impairment, with discussion of benefits and risks. This treatment improves short-term survival but increases infection risk and has no proven long-term survival benefit ¹. Non-selective beta-blockers such as carvedilol or propranolol are used to prevent decompensation and bleeding from oesophageal varices in cirrhosis ². Parenteral thiamine should be administered in suspected Wernicke's encephalopathy, followed by oral thiamine ¹. Patients with decompensated cirrhosis who remain so after 3 months of abstinence and best management should be referred for liver transplantation assessment if suitable ¹.

Regular monitoring of liver disease severity using scores like MELD every 6 months is recommended to assess risk of complications and guide management ². Referral to specialist hepatology services is advised for diagnosis confirmation, management of complications, and consideration of liver biopsy if needed ¹,².