Management Cessation of alcohol consumption is the single most impoant treatment and prognostic factor. Life-long abstinence is the best advice. General health and life expectancy are improved when this occurs, irrespective of the stage of liver disease. Abstinence is even effective at preventing progression, hepatic decompensation and death once cirrhosis is present. In the acute presentation of ALD it is impoant to identify and anticipate alcohol withdrawal and Wernicke's encephalopathy, which need treating in parallel with the liver disease and any complications of cirrhosis. Nutrition Good nutrition is very impoant, and enteral feeding a fine-bore nasogastric tube may be needed in severely ill patients. Drug therapy The optimum treatment of severe alcoholic hepatitis (Maddrey's discriminative score >32) has been debated for some time. The STOPAH study was a large, multicentre, double-blind, randomised trial to evaluate the relative merits of glucocoicoids and/or a weak anti-TNF agent (pentoxifylline), alone or in combination. In a coho of 1103 patients, no significant benefit from pentoxifylline treatment was identified but treatment with prednisolone (40 mg daily for 28 days) led to a modest reduction in sho-term moality, from 17% in placebo-treated patients to 14% in the prednisolone group. These findings were consistent with earlier studies where an improvement in 28-day survival from 52% to 78% is seen when glucocoicoids are given to those with a Glasgow score of more than 9. Neither glucocoicoids nor pentoxifylline improved survival at 90 days or 1 year, however. Sepsis is the main side-effect of glucocoicoids, and existing sepsis and variceal haemorrhage are the main contraindications to their use. If the bilirubin has not fallen 7 days after staing glucocoicoids, the drugs are unlikely to reduce moality and should be stopped. Liver transplantation The role of liver transplantation in the management of ALD remains controversial. In many centres, ALD is a common indication for liver transplantation. The challenge is to identify patients with an unacceptable risk of returning to harmful alcohol consumption. Many programmes require a 6-month period of abstinence from alcohol before a patient is considered for transplantation. Although this relates poorly to the incidence of alcohol relapse after transplantation, liver function may improve to the extent that transplantation is no longer necessary. The outcome of transplantation for ALD is good and if the patient remains abstinent there is no risk of disease recurrence. Transplantation for alcoholic hepatitis has been thought to have a poorer outcome and is seldom performed due to concerns about recidivism; studies to quantify this are ongoing. Ref Davidson edition23rd pg 882