The ICU Management of Alcoholic Liver Disease

  • Jessica L. Mellinger
  • Robert J. FontanaEmail author


Alcoholic liver disease (ALD) can present with a spectrum of clinical findings ranging from asymptomatic hepatic steatosis to life-threatening alcoholic hepatitis with jaundice or decompensated cirrhosis with ascites and protein-calorie malnutrition. Patients with alcoholic hepatitis (AH) have jaundice, coagulopathy, and a 30–60% 6-month mortality despite abstinence and supportive care. Recent data from a large multicenter study demonstrated that corticosteroids and pentoxyfilline have minimal survival benefit in AH. Therefore, many experts recommend a short course of corticosteroids only in selected AH patients whose total bilirubin levels improve within 1 week of starting treatment. ICU care for patients with ALD requires initial management of alcohol withdrawal syndromes (AWS) as well as addressing infections, bleeding, and renal failure. Management of AWS includes protocolized administration of benzodiazepines based on clinical status in a monitored setting along with correction of metabolic disturbances and supplementation of micronutrient deficiencies. Patients with severe AWS may require anti-psychotics or even propofol with intubation for severe withdrawal symptoms and cardiopulmonary instability. Treatment of upper GI bleeding in patients with ALD includes establishment of large bore IV access and early administration of IV antibiotics, proton pump inhibitors, and octreotide to further reduce bleeding. Targets for blood product replacement include a hemoglobin of 8 g/dL, an INR < 1.5 and platelets of >50 K to minimize the risk of ongoing bleeding. Following adequate gastric lavage, urgent therapeutic endoscopy is recommended to identify and treat the source of bleeding. Patients with refractory variceal bleeding may require balloon tamponade to achieve hemostasis and emergent TIPS for portal decompression. Many ICU patients with complications of ALD may develop acute kidney injury due to volume depletion, ATN, or hepatorenal syndrome. Initiation of hemodialysis in patients with ALD is frought with complications, and patients with HRS have particularly poor survival. In conclusion, management of the ICU patient with ALD requires coordinated care delivered by the intensivist in conjunction with the GI specialist and mental health provider to achieve optimal short- and long-term outcomes.


Cirrhosis Alcohol withdrawal Delirium tremens MELD score Variceal bleeding Alcoholic hepatitis 



Alcoholic hepatitis


Acute kidney injury


Alcoholic liver disease


Acute tubular necrosis


Alcohol use disorder


Alcohol withdrawal syndrome


Clinical Institute Withdrawal Assessment for Alcohol, Revised


Central nervous system


Delirium tremens


Diagnostic and Statistical Manual of Mental Disorders, 5th Edition


Diastolic blood pressure


Hepatorenal syndrome


Intensive care unit


International normalized ratio


Mean arterial pressure


Non-steroidal anti-inflammatory drugs


Spontaneous bacterial peritonitis


Transjugular intrahepatic portosystemic shunt



Grant Support: Support for Dr. Fontana provided in part by the National Institutes of Diabetes, Digestive, and Kidney Diseases (DK U-01-58369) as a member of the Acute Liver Failure Study Group. Support for Dr. Mellinger provided by an NIH NIAAA K23 Career Development Award (K23 AA026333–01).


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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of Michigan Medical CenterAnn ArborUSA

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