编者按：Mark Thursz教授是欧洲肝脏研究学会（EASL）的前任秘书长，作为2018版《EASL临床实践指南：酒精相关性肝病的管理》制定组长，他在刚刚结束的EASL年会上进行了说明。会后，《国际肝病》记者邀请到Thursz教授介绍指南重点更新，及酒精相关性肝病与肝细胞癌（HCC）的联系（文末可下载指南原文）。

 

2018版酒精相关性肝病指南有哪些重要更新？

 

Thursz教授：我想强调《指南》从命名开始的一些重要更新。“酒精性（alcoholic）”一词是一个受非议的术语，许多患者为之愤恨却无可奈何。因此，我们尽可能使用术语“酒精相关性（alcohol-related）”，如酒精相关性肝病、酒精相关性肝硬化和酒精相关性脂肪性肝炎，尽量避开“酒精性”这个词。这些术语对患者的伤害性较小。

 

我们还研究了酒精相关性肝炎患者的治疗。来自类固醇或己酮可可碱治疗酒精性肝炎（STOPAH）试验的新数据显示，使用己酮可可碱并没有任何效果，而这一治疗被上一版《指南》推荐。

 

关于使用糖皮质激素（如泼尼松龙）尚存在一些争议，在新版《指南》中我们强调糖皮质激素可考虑用于治疗严重酒精相关性肝炎患者，但由于他们不能改善患者的3个月生存率，所以使用时显然要小心谨慎些。

 

关于患者的诊断与检测，《指南》以独立的章节进行推荐。我特别想强调的一点是，乙基葡萄糖醛酸苷（ethyl glucuronide, EtG）可较好检测酒精摄入，可用于患者监测。

 

酒精性肝硬化患者发生HCC的风险如何？

 

Thursz教授：在酒精相关性肝病中，HCC究竟有多重要，这一直是一个有争议的话题。相关统计数据表明，事实上，相比于慢性乙型肝炎或丙型肝炎患者，HCC在酒精相关性肝病患者中并不常见。其中一个原因是，如果患者持续饮酒，他们很有可能死于肝衰竭而不是HCC。但令人沮丧的是，多次研究发现患者在停止饮酒后通常会发生肿瘤。

 

是否有潜在的HCC化学预防药物或措施？

 

Thursz教授：对于酒精相关性肝病，貌似有一种新的治疗方法可以阻止患者进展为HCC，但不幸的是，事实并非如此。值得注意的是，临床实践中比较重要但容易被忽略的是，这些患者应该进行定期监测。如果肿瘤可以早诊断，则可以给予患者治愈性治疗。

 

Prof. Thursz: I would like to highlight a couple of important changes to the Guidelines starting with the nomenclature. The term “alcoholic” is a stigmatizing term that many patients resent and find difficult to deal with. As a result, we have tried to move away from the term “alcoholic” wherever possible, using the term “alcohol-related” - alcohol-related liver disease, alcohol-related cirrhosis and alcohol-related steatohepatitis. These terms are less offensive to patients. 

 

We have also looked at the treatment of patients with alcohol-related hepatitis. New data from the Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial showed that there is no effect whatsoever from the use of pentoxifylline, which had been incorporated into previous guidelines. 

 

There is some controversy concerning the use of corticosteroids like prednisolone, and in the new guidelines we emphasize the fact that corticosteroids can be considered for the treatment of patients with severe alcohol-related hepatitis, but as they do not improve survival at three months, then there is clearly a note of caution there. The Guidelines also now include a section on diagnostic tests. In particular, I would like to highlight the fact that patient monitoring might include the use of ethyl glucuronide (EtG), which is a good way of detecting alcohol use. However, at this point, it is not entirely clear how frequently this should be included.

 

Prof. Thursz: This is always a controversial question - in alcohol-related liver disease, how important is hepatocellular carcinoma? The statistics would suggest that, in fact, hepatocellular carcinoma is not as common in this group of patients as it is in patients who are infected with chronic hepatitis B or C. One of the reasons for this is unfortunately if patients do not stop drinking, they are very likely to die from liver failure rather than HCC. Sadly, a repeatable finding is that patients typically develop a tumor after they have stopped drinking.

 

Prof. Thursz: It would be lovely to say that there was a new treatment available that prevented patients from developing hepatocellular carcinoma, but unfortunately, that isn’t the case. What is important, however, and sometimes neglected in clinical practice is that these patients should undergo regular surveillance. If tumors can be picked up early, then curative treatments can be applied.