The American Gastroenterological Association has issued a Clinical Practice Update on metabolic dysfunction- and alcohol-associated liver disease (MetALD), the category between MASLD and alcohol-related liver disease. It is expert review, peer reviewed but without formal evidence grading, and was published in Clinical Gastroenterology and Hepatology on 22 September.
MetALD is defined by cardiometabolic risk factors plus alcohol of about 140 to 350 g a week in women and 210 to 420 g in men. All patients with steatotic liver disease should have alcohol use assessed at first contact and at least annually. Fibrosis triage should start with FIB-4 and move to elastography or the ELF test for indeterminate or high scores, interpreting liver stiffness cautiously during active drinking. Management includes abstinence advice, micronutrient replacement (folate, thiamine, vitamin D), exercise, cardiometabolic risk treatment and pharmacotherapy for moderate or severe alcohol use disorder. Bariatric and endobariatric procedures are advised against.
For the general physician, the change is that 'fatty liver' in a patient who drinks is its own category with its own workup. Alcohol history in grams, not 'socially', is the entry point.
- Record alcohol in grams per week for every patient with steatotic liver disease.
- Use a validated questionnaire such as AUDIT-C at least annually.
- Calculate FIB-4 and refer indeterminate or high scores for elastography.
- Offer alcohol use disorder pharmacotherapy where use is moderate or severe.
- Do not refer patients with MetALD for bariatric surgery.
Why it matters
Patients with metabolic fatty liver who also drink moderately now have a defined category with distinct risks and treatment.
Don't overread it
These are expert best-practice statements without formal evidence grading.
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