Definition

Increased alcohol consumption over a prolonged period can lead to hepatic steatosis with chronic inflammation or to the development of alcohol-associated steatohepatitis (ASH) ¹. Histologically, ASH is characterized by hepatocellular ballooning, necrosis, lobular inflammation, and steatosis as key morphological features ². A critical quantity is considered to be an alcohol (ethanol) intake of 30 g per day, with gender-specific risk thresholds: 7 units for women and 14 units for men ^3,4. ASH may progress to significant liver scarring, ultimately resulting in liver cirrhosis and its associated complications.

Acute ASH presents as a sudden clinical deterioration characterized by elevated bilirubin levels, worsening liver function, and, depending on severity, hepatic encephalopathy and other complications. This acute decompensation typically occurs in patients with established liver cirrhosis or advanced fibrosis, often following continued alcohol consumption until shortly before or during the acute episode. Steroids are the primary treatment for acute ASH; however, if the patient does not respond to therapy, the prognosis is poor, with a high risk of mortality ¹.

Impact on Nutritional Status

While regular alcohol consumers are often overweight due to the additional caloric load of ethanol (7.1 kcal/g), nearly 100% of chronic alcoholics suffer from malnutrition. This is attributed to insufficient food intake (anorexia), impaired digestion and absorption of macro- and micronutrients, and increased protein catabolism ^5,6. The degree of malnutrition correlates with the severity of the disease and the prognosis. Early recognition and treatment of malnutrition is therefore crucial ⁷. In advanced chronic ASH with significant scarring, glycogen storage capacity is reduced, so prolonged fasting should be avoided to minimize protein catabolism ⁸.

Since acute alcoholic hepatitis is usually preceded by prolonged periods of increased alcohol consumption and an unbalanced, inadequate diet, clinically relevant malnutrition must be assumed in these patients ⁸.

Nutrient requirements of patients with alcohol-associated steatohepatitis. Adjustments are necessary for malnourished patients, physical activity and age of patients. The weight used is the adjusted body weight (ADJ) from a BMI of 28, otherwise the body weight before admission to hospital.
BW = body weight; d = day

Aims of Nutritional Therapy

• Maintenance or improvement of nutritional status
• Prevention of malnutrition or nutrient deficiencies
• Reduction of fasting periods to a maximum of 12 hours; for acute ASH, aim for fasting periods of no more than 8 hours
• Complete abstinence from alcohol

Energy and protein requirements should be covered by oral nutrition whenever possible. If less than 75% of the requirement is met through dietary enrichment, snacks, or sip feeds, enteral nutrition should be introduced as a supplement no later than five days. Complementary parenteral nutrition should be initiated if less than 75% of the requirement is covered by enteral and/or oral nutrition. For detailed guidance, refer to the chapter on enteral and parenteral nutrition.

General Nutrition Recommendations

Alcohol abstinence is a cornerstone of therapy and can lead to the complete restoration of liver function in cases of mild to moderate ASH ⁶. Nutritional therapy should be individualized with guidance from the clinical nutrition team to meet the specific needs of polymorbid and severely malnourished patients ⁸. This approach can improve survival rates, liver function, encephalopathy management, and infection rates ⁷.

For patients with severe acute ASH, parenteral glucose administration may be necessary (2-3 g/kg body weight per day, with dose adjustments based on blood glucose levels) ⁹.

Oral Nutrition

In principle, food can be administered orally, except in patients without a cough or swallowing reflex. Sip feeds can support the achievement of nutritional goals through oral intake and should be offered late in the evening or during the night to minimize fasting periods ⁸. In patients with encephalopathy, the use of specialized products with an increased proportion of branched-chain amino acids (BCAAs) should be considered.

Enteral Nutrition

For patients without encephalopathy who cannot meet their calorie needs orally, even with the support of oral nutritional supplements (ONS) and sip feeds, a hypercaloric enteral formula (≥1.5 kcal/mL) should be administered via a nasal or, in exceptional cases, nasogastric tube, provided there are no contraindications, such as ileus ¹⁰. There is no evidence that enteral nutrition increases the risk of encephalopathy, even in cases of severe acute ASH. However, if uncontrollable hepatic encephalopathy develops during enteral nutrition, specialized formulas with an increased content of branched-chain amino acids (BCAAs) should be considered ⁸.

Parenteral Nutrition

Water-soluble and fat-soluble vitamins as well as trace elements must be administered daily at least in the recommended daily dose from the start of parenteral nutrition. If the fasting period lasts longer than 72 hours, complete parenteral nutrition is indicated ⁸.

It is recommended to use standard nutrient solutions for both enteral and parenteral nutrition, as no studies have demonstrated superior efficacy of specialized products over standard formulations.

Practical Tips (if indicated)

• Recommended meal composition to meet increased energy and protein requirements:
  • Include a starchy side dish with each main meal, ensuring that starchy foods make up the largest portion of the meal by quantity.
  • Add a protein side dish to each main meal, incorporating both animal and plant protein sources; adjust protein intake according to individual requirements.
  • Use fats and oils for food preparation and enrichment of menu components.
  • Incorporate vegetables and salads, but reduce their quantity (caution: they are high in volume but low in energy and protein) or omit them if they contribute to a feeling of fullness.
  • Regularly include energy-dense foods, such as sweetened beverages, fruit juices, sweets, desserts, nuts, and sweeteners (e.g., sugar or honey).
• Avoid long fasting periods: Sip feeding, carbohydrate- and protein-rich snacks, a late-night meal, and an early morning meal are preferable alternatives to nocturnal enteral nutrition ⁸.

Monitoring

• Vitamin supplementation: Patients with steatorrhea, cholestasis, or bile salt deficiency; particularly those with chronically increased alcohol consumption, often exhibit deficiencies in fat-soluble vitamins.
• Routine vitamin B supplementation is often indicated due to the high prevalence of deficiencies.
• Zinc supplementation is frequently indicated early due to the high prevalence of deficiency; zinc is an important trace element necessary for protein synthesis, among other functions.
• Vitamin A and zinc supplementation: to indirectly improve nutritional status by enhancing gustatory function.
• Assessment of malnutrition using anthropometric measurements such as BMI, triceps skinfold thickness, mid-arm muscle area (MAMA), bioimpedance analysis, or indirect measurement of muscle mass using 24-hour creatinine (1 g creatinine in urine = 18.5 kg muscle mass; caution: prone to error due to cumulative errors) ^6,8.

Medications/Supplements

• Vitamin preparations:
  • Thiamine
  • Vitamin B complex
  • Folic acid
  • Multivitamin preparations
• Zinc