Alcohol-Associated Pancreatitis Confers Higher Risk of Advanced Liver Disease Than Alcohol Withdrawal Syndrome

Background and aim Alcohol-associated liver disease frequently presents late as decompensated cirrhosis, representing a missed opportunity for intervention. Extrahepatic alcohol-related presentations requiring acute care, such as alcohol-associated pancreatitis and alcohol withdrawal syndrome, may identify heavy drinkers at varying risk for liver disease progression. Whether these presentations differentially predict progression to advanced chronic liver disease is unknown. Methods This retrospective cohort study used a United States federated database. Adults with a first diagnosis of alcohol-associated pancreatitis or alcohol withdrawal syndrome (2016-2023) without pre-existing liver disease were included. Cohorts were propensity score-matched on demographics, comorbidities, laboratory values, and medications. The primary outcome was advanced chronic liver disease. Secondary outcomes included all-cause mortality and prescription of medications for alcohol use disorder. Results After matching, 3201 patients per cohort were analyzed. Over median follow-up of 3.5-3.7 years, patients with alcohol-associated pancreatitis had higher rates of advanced chronic liver disease (9.3% vs. 7.0%; hazard ratio, 1.29; 95% confidence interval, 1.09-1.54; p = 0.004), driven by hepatic decompensation (7.0% vs. 4.6%; hazard ratio, 1.50; 95% confidence interval, 1.22-1.85; p < 0.001). Conversely, patients with alcohol withdrawal syndrome had higher all-cause mortality (12.7% vs. 9.5%; p < 0.001) and medications for alcohol use disorder prescriptions (15.1% vs. 7.7%; p < 0.001). Negative control analyses supported robustness of findings. Conclusions Among patients without pre-existing liver disease, alcohol-associated pancreatitis was associated with 29% higher advanced chronic liver disease risk compared with alcohol withdrawal syndrome and may serve as an early marker of hepatotoxic susceptibility supporting prioritized liver surveillance.