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Article

Patterns and Outcomes of Alcoholic Liver Disease (ALD) in Oman: A Retrospective Study in a Culturally Conservative Context

by
Said A. Al-Busafi
1,
Thuwiba A. Al Baluki
2 and
Ahmed Alwassief
3,*
1
Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat 123, Oman
2
Department of Medicine, Sohar Hospital, Ministry of Health, Muscat 100, Oman
3
Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman
*
Author to whom correspondence should be addressed.
Livers 2025, 5(3), 38; https://doi.org/10.3390/livers5030038
Submission received: 26 June 2025 / Revised: 28 July 2025 / Accepted: 7 August 2025 / Published: 18 August 2025
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Abstract

Background: Alcoholic liver disease (ALD) contributes substantially to global liver-related morbidity and mortality. In conservative societies such as Oman, data on ALD are scarce due to stigma and legal constraints. This study aims to characterize the clinical spectrum, complications, and outcomes of ALD in Oman, providing the first detailed analysis from a tertiary care setting in the country. Methods: We retrospectively analyzed 131 Omani patients with documented unhealthy alcohol use from 2012 to 2018 at Sultan Qaboos University Hospital. ALD diagnosis was based on clinician judgment per EASL guidelines and DSM-5 criteria, where applicable. Data included demographics, clinical/laboratory findings, and radiologic/endoscopic features. Associations with complications and mortality were assessed using chi-square tests and logistic regression. Results: Of 131 patients, 84 (64.1%) were diagnosed with ALD: fatty liver (34.5%), alcoholic hepatitis (20.2%), cirrhosis (40.5%), and hepatocellular carcinoma (4.8%). Cirrhosis was significantly more prevalent in patients aged 50 years or older (OR = 2.53, 95% CI: 1.02–6.28; p = 0.048). Ascites and portal hypertension were strongly associated with mortality (OR = 5.20, CI: 1.85–14.6 and OR = 6.13, CI: 2.04–18.4, respectively; p < 0.01). Overall mortality in ALD was 28.6%, increasing to 44.1% in cirrhotics. Conclusion: ALD is a significant yet underrecognized problem in Oman, with high rates of late-stage presentation and mortality. Early detection and culturally tailored strategies are needed to improve care outcomes.

1. Introduction

Alcoholic liver disease (ALD) is a significant global health concern and one of the leading causes of chronic liver disease. ALD encompasses a spectrum of hepatic disorders, ranging from alcoholic fatty liver disease (AFLD) and alcoholic hepatitis (AH) to cirrhosis and hepatocellular carcinoma (HCC) [1]. The progression of ALD is influenced by the quantity and duration of alcohol consumption, genetic predisposition, and concurrent liver insults such as viral hepatitis and metabolic disorders [2]. Early-stage ALD is often asymptomatic, while advanced disease presents with complications including portal hypertension, ascites, variceal bleeding, and hepatic encephalopathy (HE) [3].
Diagnosis typically relies on a history of alcohol use, clinical findings, and laboratory markers and by excluding other causes of liver injury or cirrhosis, with liver biopsy reserved for ambiguous cases [1,4]. In one study, clinical findings had a sensitivity and specificity of 91% and 97%, respectively, for diagnosing ALD when compared with liver biopsy as the gold standard [5]. Obtaining a very detailed history to quantify alcohol use and drinking patterns is difficult most of the time, because patients who drink alcohol in excess are prone to feel guilty and frequently give misleading answers [5]. Despite the availability of pharmacological and supportive interventions, liver transplantation remains the definitive treatment for end-stage ALD [6].
Globally and in the United States (U.S.), liver transplantation due to ALD has experienced significant trends and shifts in recent years. In the U.S., ALD has become the leading indication for liver transplantation, surpassing other causes such as hepatitis C and HCC [7,8,9]. This trend is reflected worldwide, where ALD remains a major public health concern, contributing significantly to disease burden and premature mortality [10]. The prevalence of ALD is particularly high among younger adults [10].
In the U.S., liver transplants due to ALD rose sharply from 12.8% in 2002 to 48% in 2022, largely driven by increased acceptance of transplantation for alcoholic hepatitis (AH) despite prior abstinence guidelines [9,11,12]. Similar trends are observed in Europe, where ALD has also become a leading indication for transplantation [10]. Nevertheless, ALD remains underdiagnosed, often due to social stigma and challenges in accurately assessing alcohol use history [5].
While most epidemiological data on ALD come from Western countries, recent evidence indicates a growing burden in the Middle East and North Africa (MENA) region, even in the face of religious and legal restrictions on alcohol use. Between 1990 and 2021, the incidence of chronic liver disease in MENA more than doubled, rising by over 114%, with alcohol use emerging as a notable yet often underreported contributor [13]. In 2019 alone, alcohol-related conditions were estimated to have caused more than 22,000 deaths and 1.1 million disability-adjusted life years (DALYs) across MENA countries, with liver cirrhosis comprising a significant portion of this toll [14,15].
Despite this growing public health concern, alcohol use remains heavily stigmatized in the region, which contributes to underdiagnosis and misclassification of ALD. Oman, like many Gulf nations, faces unique challenges in recognizing and addressing alcohol-related harm. These include strong sociocultural taboos, limited patient disclosure, and a scarcity of robust research data. This study was designed to bridge that knowledge gap by presenting the first comprehensive clinical profile of ALD in Oman.
Although extensive data are available from Western populations, regional patterns of ALD, particularly in the MENA region, remain poorly understood. In Oman, religious and cultural norms often prevent accurate reporting of alcohol consumption, likely masking the true prevalence of ALD and delaying diagnosis [16]. While limited local evidence suggests that ALD is a growing concern, its overall burden and clinical characteristics remain largely undefined. This underscores the urgent need for targeted public health strategies, which this study seeks to inform.
To address the regional knowledge gap, this study aims to provide the first comprehensive clinical assessment of alcohol-associated liver disease (ALD) in Oman. We examine its demographic characteristics, clinical presentations, complications, and outcomes in patients treated at a tertiary care center, with the goal of identifying key prognostic factors and informing targeted, culturally sensitive interventions. Given the stigma surrounding alcohol use in Oman, our findings are intended to support earlier diagnosis, enhance clinical care, and inform culturally appropriate public health policies tailored to conservative settings.

2. Materials and Methods

2.1. Study Design

This is a retrospective descriptive, hospital-based analysis conducted at Sultan Qaboos University Hospital (SQUH) in Muscat, Oman using a structured and standardized approach to evaluate past patient records and identify trends, characteristics, and outcomes of ALD in the Omani population. Data was extracted from the TrakCare electronic medical record system at SQUH, encompassing patients who were admitted with a confirmed diagnosis of ALD between 1 January 2012 and 31 December 2018. For each patient, the index admission was defined as the first documented hospital encounter for ALD during the study period. Clinical outcomes, including complications and mortality, were assessed from the date of the index admission to the last available follow-up recorded in the hospital’s electronic health system, with follow-up durations ranging from 1 month to 7 years.
Ethical approval for the study was obtained from the Medical Research & Ethics Committee of the College of Medicine & Health Sciences, Sultan Qaboos University. Given the retrospective nature of the study and the use of de-identified data, informed consent was waived. Measures were implemented to ensure patient confidentiality and data security, underscoring the thoroughness and integrity of our research.

2.2. Patient Selection and Definitions

The study included all Omani patients aged ≥18 years who had documented unhealthy alcohol use. All records with relevant ICD-10 diagnostic codes for alcohol use (e.g., F10.x series), alcohol-related liver disease (e.g., K70.x), or liver disease of unclear etiology were screened [17]. Patients were included if they met clinical criteria for ALD based on a documented history of unhealthy alcohol use and the exclusion of other known causes of liver disease (e.g., viral hepatitis, autoimmune liver disease, Wilson’s disease, hemochromatosis).
Unhealthy alcohol use was defined pragmatically as alcohol consumption associated with liver injury, as judged by the treating physician and in accordance with European Association for the Study of the Liver (EASL) guidelines [18]. While precise quantities of alcohol could not be reliably quantified due to sociocultural factors, clinical diagnosis was supported by typical laboratory findings (elevated AST > ALT, elevated GGT, macrocytosis), and imaging features (hepatic steatosis, nodular liver contour, signs of portal hypertension) in the appropriate context.
Because quantitative consumption data were not consistently available, dose–response analysis was not feasible; however, the composite clinical–laboratory–imaging approach provided a robust surrogate for identifying clinically significant alcohol-related liver injury in this socioculturally constrained context. Liver biopsy was not routinely performed.
We acknowledge that referral and selection bias may exist, as SQUH is a tertiary referral center and cases presenting with milder disease may be underrepresented. Only patients with complete diagnostic information and confirmed alcohol-related liver injury were included in the final analysis.
For clarity, we adopted the term “unhealthy alcohol use” throughout this study to reflect alcohol consumption that resulted in liver injury or clinical harm, based on physician judgment and supporting clinical findings. This term was chosen deliberately due to sociocultural and legal constraints that limit patients’ disclosure of alcohol use in Oman. As a result, standardized DSM-5 diagnostic criteria for alcohol use disorder could not always be applied retrospectively. When possible, clinician assessment was guided by DSM-5 behavioral criteria to infer the presence of alcohol use disorder. The terms “dependence” and “addiction” were intentionally avoided to maintain consistency and avoid overlap with older or non-clinical nomenclature.

2.3. Data Collection

We retrospectively reviewed the electronic medical records of all eligible patients to extract relevant clinical data. The following variables were collected:
  • Demographic information: age, sex, nationality, and known comorbidities (e.g., diabetes, hypertension, viral hepatitis, and metabolic syndrome).
  • Alcohol history: pattern, frequency, and duration of alcohol consumption based on available clinical notes and social history.
  • Clinical presentation at index admission: symptoms such as jaundice, ascites, hepatic encephalopathy, gastrointestinal bleeding, and signs of decompensated liver disease.
  • Laboratory parameters: liver function tests (AST, ALT, total and direct bilirubin, alkaline phosphatase, gamma-glutamyl transferase), coagulation profile (INR), renal function (creatinine, urea), serum albumin, complete blood count, and markers of synthetic liver function.
  • Radiological findings: abdominal ultrasound and/or CT imaging reports were reviewed to assess for hepatomegaly, liver echotexture, splenomegaly, ascites, and portosystemic collaterals.
  • Portal hypertension: this was defined using a combination of clinical, laboratory, imaging, and endoscopic criteria; these included the presence of splenomegaly, thrombocytopenia (platelet count <150,000/μL), ascites, or portosystemic collaterals detected on imaging (ultrasound or CT), as well as esophageal or gastric varices documented via upper gastrointestinal endoscopy.
  • Mortality data: these were retrieved from hospital records and follow-up visits, including the date and cause of death when available.
Due to the retrospective nature of the study, formal liver severity scores such as MELD or Child–Pugh were not consistently recorded and could not be uniformly calculated across the entire cohort. Although key biochemical parameters (e.g., AST, ALT, bilirubin, INR, and albumin) were available for most patients, they were not always documented at the time of initial presentation, limiting their use in standardized scoring. This limitation highlights the need for prospective studies with structured clinical documentation.

2.4. Complication Assessment

Complications were analyzed at two key time points: first, those present at the initial presentation (index hospitalization or first documented encounter with ALD-related diagnosis), and second, those that developed during the overall course of follow-up. Complications assessed included ascites, hepatic encephalopathy (HE), variceal bleeding, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and upper gastrointestinal bleeding (UIGB). This approach enabled the distinction between early disease manifestations and complications that arose later, providing a more comprehensive understanding of disease progression.

2.5. Statistical Analysis

We analyzed data using the Statistical Package for the Social Sciences (SPSS), Version 20. Descriptive statistics were employed to summarize demographic and clinical characteristics. Categorical variables were analyzed using chi-square tests for independence, and Fisher’s exact test was used where expected cell counts were low (e.g., for HCC and other sparse categories). Binary logistic regression was selectively applied to assess associations between key variables, such as age group and cirrhosis, and between complications (e.g., ascites, portal hypertension) and mortality.
Given the retrospective design and modest sample size, multivariable adjustment for potential confounders, such as age, sex, diabetes, and smoking, could not be performed robustly. This limitation is acknowledged in the discussion. To compare disease prevalence and mortality outcomes between age groups and ALD subtypes, chi-square or Fisher’s exact tests were selected based on sample size and cell distribution. The study was not powered for multivariable modeling due to sample size constraints and incomplete data on confounders.

3. Results

3.1. Demographic Characteristics and ALD Manifestations

A total of 131 Omani patients with unhealthy alcohol use were analyzed, of whom 84 (64.1%) developed ALD (Figure 1).
The cohort was predominantly male (94.6%). Among ALD patients, cirrhosis was the most common diagnosis (40.5%, n = 34), followed by isolated fatty liver (34.5%, n = 29), AH (20.2%, n = 17), and hepatocellular carcinoma (HCC; 4.8%, n = 4). Age significantly influenced disease severity: cirrhosis and HCC were more prevalent in patients aged 50 years or older (50.0% and 8.7%, respectively) compared to those aged younger than 50 years (28.9% and 0.0%; p = 0.048 for cirrhosis). Fatty liver was more common in younger patients (44.7% vs. 26.1% in ≥50 years), although this difference did not reach statistical significance (p = 0.08) (Table 1).

3.2. Clinical Presentation Across ALD Stages

Abdominal pain was the most common initial symptom overall, reported in 44.1% of cirrhotic patients, 44.8% of fatty liver cases, and 41.2% of AH cases (p = 0.93). Jaundice showed a strong association with AH (47.1% vs. 0.0% in fatty liver and 8.8% in cirrhosis; p = 0.001). Abdominal distention was significantly more prevalent in cirrhosis (14.7%, p = 0.030). Upper gastrointestinal bleeding (UGIB) occurred in 29.4% of cirrhotic patients but did not differ significantly among groups (p = 0.21) (Table 2).

3.3. Complications in ALD Patients: Initial Presentation and Overall Course

Among the 84 ALD patients, complications at both initial presentation and during follow-up varied significantly by disease stage (Table 3). Cirrhotic patients most frequently presented with upper gastrointestinal bleeding (UGIB; 44.1%, n = 15/34) or ascites (32.4%, n = 11/34), both of which were strongly associated with cirrhosis (p = 0.001). In contrast, 27.6% (n = 8/29) of fatty liver patients and 35.3% (n = 6/17) of those with alcoholic hepatitis (AH) had no complications at the time of diagnosis, compared to only 5.9% (n = 2/34) among cirrhotic patients (p = 0.019).
Over the course, complications were significantly more common in cirrhosis. UGIB occurred in 58.8% of cirrhotic patients (n = 20/34), compared to 20.7% in fatty liver (n = 6/29) and 29.4% in AH (n = 5/17; p < 0.001). Hepatic encephalopathy (HE) was observed in 29.4% of cirrhotic patients, while portal hypertension and ascites were nearly exclusive to cirrhosis (82.4% and 76.5%, respectively; p < 0.001). Spontaneous bacterial peritonitis (SBP) occurred in 26.5% of cirrhotics, but the difference did not reach statistical significance (p = 0.064). Hepatocellular carcinoma (HCC) was diagnosed in four patients (4.8%), with three cases among cirrhotics and one in the AH group.

3.4. Mortality and Health Status

Overall, 24 of 84 ALD patients (28.6%) died during the study period. The median duration from initial presentation to death or last follow-up was 18.2 months (IQR: 9.1–31.7 months). Mortality increased with disease severity: 44.1% of cirrhotic patients (n = 15/34), 35.3% of those with alcoholic hepatitis (n = 6/17), and 10.3% of patients with fatty liver (n = 3/29) died (p < 0.001; Table 4). Of the 24 deaths, 79.2% (n = 19) were attributable to liver-related causes (e.g., sepsis, massive UGIB, or HRS), while 3 deaths were likely unrelated (1 trauma, 1 perforated peptic ulcer, 1 unknown), and 2 had indeterminate etiology.
Cirrhosis conferred the highest mortality burden, with deaths occurring nearly 4.3 times more frequently than in non-cirrhotic stages (p < 0.001). Critical care admissions were required for 23.8% (n = 20/84) of patients, predominantly for sepsis or refractory UGIB. Portal hypertension, detected in 82.4% of cirrhotic patients (n = 28/34), strongly correlated with mortality (p < 0.001), underscoring its role as a prognostic marker.

3.5. Causes of Death

The most common causes of death in patients with ALD included sepsis (66.7%), massive UGIB (57.1%), and hepatorenal syndrome (HRS) (100% of two cases). Other causes of death included perforated peptic ulcer disease (PUD) (one case) and trauma (fall) (one case in AH). Notably, no deaths were attributed to HCC, highlighting the importance of other complications in ALD mortality. In some cases, the cause of death remained undetermined (Table 5).

4. Discussion

This study provides the first comprehensive evaluation of ALD in Oman and potentially the wider Gulf region, a topic rarely addressed due to prevailing religious and cultural taboos surrounding alcohol use. To our knowledge, this is the first study to comprehensively describe the clinical spectrum and outcomes of ALD specifically within the Omani population. Our findings offer crucial clinical and epidemiological insights into ALD in a context where the true burden is often masked by underreporting and stigma. Consequently, our results provide foundational data essential for future research, policy formulation, and health service planning targeting alcohol-related liver disease in the Gulf region.
Although alcohol consumption is legally restricted, it persists in the Gulf region [19]. In 2016, alcohol use in the Eastern Mediterranean was estimated at 6.2%, with increasing trends despite cultural deterrents [20]. In Oman, hazardous drinking has been observed even among psychiatric patients [21], yet those who seek medical care likely represent only a fraction of actual users. Persistent underreporting is driven by multiple factors, including social stigma, methodological constraints in surveillance systems, and widespread reluctance to disclose alcohol-related behaviors [10,22]. These barriers not only obscure the scale of alcohol use but also delay clinical recognition and timely intervention for ALD.
While we did not collect quantitative or qualitative data on stigma directly, our observations were based on consistent patterns in clinical documentation—such as patients’ reluctance to disclose alcohol use, reliance on family or physician suspicion, and lack of standardized reporting. These impressions are also supported by prior regional studies documenting alcohol underreporting in conservative societies. We have clarified in the manuscript that our discussion of stigma is contextual and not based on formal survey or interview data within this study. Nonetheless, we believe it provides an essential background for interpreting diagnostic delays and disease severity in this setting.
Global interventions, such as alcohol taxation, have demonstrated effectiveness but may not translate easily to Gulf societies due to sociocultural complexities [23]. This underscores the need for culturally adapted screening, treatment, and public health strategies [24,25]. Our findings directly address this gap, offering real-world data from a region where ALD has been largely invisible in research and policy discourse.
A recent meta-analysis estimated that 51% of individuals with alcohol use disorders develop ALD [26]. In our study, this proportion was even higher: 64.1% of Omani patients with unhealthy alcohol use were diagnosed with ALD, with cirrhosis being the most common presentation (40.5%). This exceeds the global estimate cited in a recent review [26] and surpasses the reported global prevalence of cirrhosis among heavy drinkers, which ranges from 10% to 20% [27,28].
Several factors are likely to contribute to this discrepancy. The high rates of ALD and cirrhosis observed in our cohort may reflect both delayed clinical presentation and the underdiagnosis of milder disease stages. In Oman, as in many conservative societies, stigma, legal implications, and cultural taboos surrounding alcohol use often deter individuals from seeking timely medical care or disclosing their drinking habits. Consequently, patients may only present when their condition has progressed to an advanced stage. This pattern highlights the urgent need for earlier identification and culturally tailored public health interventions. Our findings highlight a significant but underrecognized disease burden, which remains hidden due to social and legal barriers [29].
Regionally, the MENA region has witnessed a 114.9% increase in the incidence of chronic liver disease between 1990 and 2021 [13]. In 2019 alone, alcohol-related conditions were estimated to have caused more than 22,000 deaths and 1.1 million DALYs in the MENA region, spanning a wide spectrum of alcohol-attributable diseases beyond liver injury [14,15]. These numbers underscore the growing health and economic toll of alcohol use in the region, despite cultural and legal restrictions, and reinforce the need to develop responsive, stigma-aware healthcare infrastructure [30].
Our study also highlights age-related trends. Patients aged 50 and older were more likely to present with cirrhosis or HCC, whereas younger individuals more commonly had isolated fatty liver disease. This aligns with evidence showing that aging exacerbates liver vulnerability due to reduced hepatic regeneration, immune dysregulation, and slower alcohol metabolism [31,32]. Delayed recognition and underdiagnosis in older adults, driven by low awareness, stigma, and limited access to care, are also patterns observed in hepatitis B and C [33,34], and they contribute to poor outcomes [35,36]. These findings support the need for age-specific screening and early referral protocols.
Gender-related disparities were striking. Nearly 95% of ALD patients were male, reflecting cultural norms where alcohol use is more socially acceptable, or at least more openly disclosed, among men [37,38,39,40]. However, the presence of ALD in 5.4% of women is clinically and socially significant in a context where female alcohol consumption is highly stigmatized and often hidden. This likely represents only a fraction of the true burden, as women may be less likely to report alcohol use or seek timely care due to heightened societal shame and legal concerns [41]. Furthermore, existing evidence indicates that women are biologically more vulnerable to alcohol-related liver injury, with more rapid disease progression and worse outcomes at lower cumulative doses of alcohol [42]. These dual vulnerabilities—biological susceptibility and systemic barriers—may result in women presenting at more advanced stages of disease. Unfortunately, our sample size did not permit meaningful sex-based subgroup analysis; however, this is a critical area for future research. Tailored, gender-sensitive screening strategies and culturally safe care pathways are urgently needed to address these disparities and ensure equitable access to diagnosis and treatment for women with ALD [43]. We observed substantial complication and mortality rates. Among patients with ALD, 28.6% died, and this rose to 44.1% in those with cirrhosis. Complications such as ascites, portal hypertension, upper gastrointestinal bleeding, and hepatic encephalopathy were common and severe. These outcomes mirror global data linking advanced ALD with poor prognosis [10,44]. In Oman, alcohol has become a significant contributor to cirrhosis-related mortality, with local studies reporting death rates nearing 40%, a trend that aligns with the severity observed in our cohort [30]. Yet despite improvements in regional healthcare systems, timely diagnosis and care remain limited, especially in socially conservative settings [44,45].
To improve benchmarking and interpretability, we clarified the median follow-up duration (18.2 months) and categorized causes of death. The majority (79.2%) were liver-related, consistent with the high rates of cirrhosis and portal hypertension in our cohort. While severity scores, such as MELD or Child–Pugh, were not routinely captured in patient records during the study period, this highlights an important methodological gap that future prospective studies should address to enable risk stratification and mortality prediction. These additions provide a clearer picture of outcome trajectories and allow for better contextualization with global data.
To effectively reduce the burden of ALD in Oman and other conservative Middle Eastern societies, policy approaches must be both culturally sensitive and grounded in regional best practices. Public health strategies should extend beyond clinical settings to include multisectoral collaboration, such as engaging religious leaders, educators, and community organizations, to promote alcohol awareness and reduce stigma [22,46]. For instance, models from Qatar and the UAE demonstrate that culturally adapted outreach programs, like the UAE’s National Rehabilitation Centre and Qatar’s Recovery Journey model, deliver structured care while respecting local values, including leveraging religiosity as a protective factor against substance use [47,48]. These examples underscore the importance of tailoring interventions to the social and psychological context of the population. In Oman, similar initiatives could be anchored in the country’s Health Vision 2050 goals by incorporating alcohol risk reduction into broader non-communicable disease (NCD) strategies and mental health services [49,50]. Policymakers might also consider implementing frameworks like the Alcohol Preparedness Index (API) to evaluate and strengthen alcohol-related interventions while enhancing health promotion capacity through professional training and community engagement. By combining culturally grounded prevention efforts with system-level reform and sustained public education, Oman and similar nations can advance a holistic response to ALD that is both effective and culturally aligned.
This study has several limitations. As a retrospective review, it relied on the accuracy and completeness of medical records, which may have introduced information bias, particularly concerning alcohol use due to cultural stigma and legal sensitivities. Precise quantification of alcohol intake was not feasible, as patients often underreported consumption or withheld details entirely. As a result, dose–response relationships could not be evaluated. To address this, we employed a pragmatic diagnostic approach aligned with EASL guidelines, incorporating clinical history, laboratory findings (e.g., AST > ALT, elevated GGT, macrocytosis), and imaging evidence (e.g., hepatic steatosis, nodular liver contour, portal hypertension) while excluding other potential etiologies of liver disease. However, ALD diagnosis was not histologically confirmed in all cases.
Importantly, the lack of liver biopsy or elastography introduces the possibility of diagnostic misclassification, particularly between fatty liver and steatohepatitis or early cirrhosis. This may lead to either underestimation or overstatement of disease severity, particularly in borderline or early cases.
From a statistical standpoint, the relatively small sample size and the presence of sparse cells in several contingency tables limited our ability to perform multivariable modeling to adjust for potential confounders such as age, sex, diabetes, or smoking. While we conducted descriptive analyses, chi-square tests, and binary logistic regression for select variables (e.g., cirrhosis and mortality), the study was not powered for comprehensive adjusted modeling, and caution is warranted when interpreting associations. Future studies with larger, multicenter cohorts will be essential for confirming these findings and enabling more robust multivariate analyses.
Additionally, key biochemical parameters required to compute validated prognostic scores, such as MELD or Child–Pugh, were not consistently available across the study population, precluding reliable disease severity stratification. This limitation highlights the importance of standardized and prospective data collection to facilitate more robust clinical risk assessment in future studies of ALD, particularly in settings where retrospective analyses are hindered by variability in documentation.
Furthermore, because the data were drawn from a single tertiary referral center, the study may not accurately reflect the full disease spectrum in the general population, particularly for milder or undiagnosed cases. Selection bias is also possible, and the relatively small sample size limited our ability to conduct robust subgroup analyses (e.g., by sex or HCC status). Despite these constraints, this study provides the first detailed clinical assessment of ALD in Oman, offering a crucial foundation for advancing epidemiological understanding, surveillance efforts, and culturally appropriate public health strategies in the region.
Because the data were drawn from a single tertiary referral center, the study may not accurately reflect the full disease spectrum in the general population, particularly for milder or undiagnosed cases. Selection bias is also possible, and the relatively small sample size limited our ability to conduct robust subgroup analyses (e.g., by sex or HCC status). Despite these constraints, this study provides the first detailed clinical assessment of ALD in Oman, offering a crucial foundation for advancing epidemiological understanding, surveillance efforts, and culturally appropriate public health strategies in the region.

5. Conclusions

This study reveals a significant and underrecognized burden of ALD in Oman, despite strong cultural and religious deterrents to alcohol use. ALD predominantly occurred in males and often presented at advanced stages, particularly among older adults. Moreover, the presence of female cases, even in this conservative context, signals shifting norms and necessitates the development of gender-sensitive screening and care pathways that address the unique barriers women face when seeking help for alcohol-related disorders. Cirrhosis emerged as the most common and severe form, linked to a high complication rate and mortality. Ascites and portal hypertension were identified as key predictors of poor prognosis.
Clinicians in Oman should maintain a high index of suspicion for ALD in patients presenting with abnormal liver enzymes—particularly elevated AST > ALT, raised GGT, or macrocytosis on CBC—alongside compatible imaging findings such as hepatic steatosis, nodular liver contour, or signs of portal hypertension. Additional clinical cues include a history of unexplained jaundice, recurrent UGIB, ascites, or hepatic encephalopathy in patients without clear alternative causes. In such cases, further liver function evaluation (e.g., INR, bilirubin, albumin), abdominal imaging, and referral to hepatology should be considered—even if the patient does not openly report alcohol use.
From a policy perspective, healthcare systems should consider integrating opportunistic alcohol screening and liver function assessment into emergency care, internal medicine, and psychiatric clinics, where patients may first present with complications related to ALD. Establishing non-judgmental screening environments and clinician training programs can support early detection in high-risk patients.
A critical next step involves implementing and evaluating targeted screening programs in high-risk populations, as well as establishing clear referral pathways for identified cases. Facilitating broader targeted interventions and enhancing access to hepatology care may mitigate the disease burden and improve outcomes in this vulnerable population.

Author Contributions

S.A.A.-B., T.A.A.B. and A.A. contributed to the study concept and design, data acquisition, statistical analysis, interpretation, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. S.A.A.-B. and A.A. also contributed to the study through administrative, technical, or material support, as well as study supervision. All authors have read and agreed to the published version of the manuscript.

Funding

No funding was received for this research.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Medical Research Ethics Committee of the College of Medicine and Health Sciences, Sultan Qaboos University, on 1 June 2016 (protocol code: MREC#1290).

Informed Consent Statement

Given the retrospective nature of the study and the use of de-identified data, informed consent was waived.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

Acknowledgments

The authors acknowledge the use of artificial intelligence (AI) tools, specifically OpenAI’s ChatGPT, for assistance with English language editing and proofreading during the preparation of this manuscript. All content was reviewed and approved by the authors to ensure accuracy and integrity.

Conflicts of Interest

The authors declare no conflicts of interest.

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Livers 05 00038 g001
Figure 1. Flowchart of patient selection and classification into alcohol-associated liver disease (ALD) subtypes. Abbreviations: SQUH, Sultan Qaboos University Hospital; ALD, alcohol-associated liver disease; EASL, European Association for the Study of the Liver; HCC, hepatocellular carcinoma.
Figure 1. Flowchart of patient selection and classification into alcohol-associated liver disease (ALD) subtypes. Abbreviations: SQUH, Sultan Qaboos University Hospital; ALD, alcohol-associated liver disease; EASL, European Association for the Study of the Liver; HCC, hepatocellular carcinoma.
Livers 05 00038 g001
Table 1. Alcohol-associated liver disease manifestations by age group (n = 84).
Table 1. Alcohol-associated liver disease manifestations by age group (n = 84).
ALD StageTotal, n (%)Age < 50, n/N (%)Age ≥ 50, n/ (%)p-Value
Fatty liver29 (34.5%)17/38 (44.7%)12/46 (26.1%)0.08
Alcoholic hepatitis17 (20.2%)10/38 (26.3%)7/46 (15.2%)0.21
Cirrhosis34 (40.5%)11/38 (28.9%)23/46 (50.0%)0.048 *
HCC4 (4.8%)0/38 (0.0%)4/46 (8.7%)0.10
Abbreviations: ALD, alcoholic liver disease; HCC, hepatocellular carcinoma. N = total patients in the age group. Percentages reflect proportions within age strata. * Indicates statistical significance (p < 0.05).
Table 2. Clinical presentations by alcoholic disease stage (n = 80) (excluding 4 cases of hepatocellular carcinoma).
Table 2. Clinical presentations by alcoholic disease stage (n = 80) (excluding 4 cases of hepatocellular carcinoma).
PresentationFatty Liver (n = 29), n (%)Alcoholic Hepatitis (n = 17), n (%)Cirrhosis (n = 34), n (%)p-Value
Abdominal pain13 (44.8%)7 (41.2%)15 (44.1%)0.93
UGIB3 (10.3%)5 (29.4%)10 (29.4%)0.21
Abdominal distention0 (0.0%)1 (5.9%)5 (14.7%)0.030 *
Jaundice0 (0.0%)8 (47.1%)3 (8.8%)0.001 *
Thrombocytopenia0 (0.0%)1 (5.9%)1 (2.9%)0.61
Trauma (fall)0 (0.0%)3 (17.6%)1 (2.9%)0.17
Abbreviations: AST, aspartate aminotransferase; ALT, alanine aminotransferase; INR, international normalized ratio; ALP, alkaline phosphatase; GGT, gamma-glutamyl transferase; UIGB, upper intestinal gastrointestinal bleeding; HE, hepatic encephalopathy. Percentages reflect proportions within each ALD stage. * Indicates statistical significance (p < 0.05).
Table 3. Complications by alcoholic liver disease stage—initial presentation vs. overall course (n = 84).
Table 3. Complications by alcoholic liver disease stage—initial presentation vs. overall course (n = 84).
ComplicationFatty Liver (n = 29)Alcoholic Hepatitis (n = 17)Cirrhosis (n = 34)p-Value
No complication (first)8 (27.6%)6 (35.3%)2 (5.9%)0.019 *
Ascites0 (0.0%)
→ 0 (0.0%)		3 (17.6%)
→ 9 (52.9%)		11 (32.4%)
→ 26 (76.5%)		<0.001 *
UGIB2 (6.9%)
→ 6 (20.7%)		2 (11.8%)
→ 5 (29.4%)		15 (44.1%)
→ 20 (58.8%)		<0.001 *
HE0 (0.0%)
→ 0 (0.0%)		0 (0.0%)
→ 2 (11.8%)		1 (2.9%)
→ 10 (29.4%)		0.002 *
Portal hypertension0 (0.0%)
→ 0 (0.0%)		0 (0.0%)
→ 6 (35.3%)		0 (0.0%)
→ 28 (82.4%)		<0.001 *
SBP—
→ 0 (0.0%)		—
→ 2 (11.8%)		—
→ 9 (26.5%)		0.064
HCC0 (0.0%)
→ 0 (0.0%)		1 (5.9%)
→ 1 (5.9%)		3 (8.8%)
→ 3 (8.8%)		0.072
Abbreviations: UGIB, upper gastrointestinal bleeding; HE, hepatic encephalopathy; SBP, spontaneous bacterial peritonitis; HCC, hepatocellular carcinoma. Notes: Values are expressed as first presentation → overall incidence during follow-up. Percentages reflect proportions within each ALD stage. * Indicates statistical significance (p < 0.05). Fisher’s exact test was used for small expected cell counts.
Table 4. Mortality outcomes by alcoholic liver disease stage (n = 80).
Table 4. Mortality outcomes by alcoholic liver disease stage (n = 80).
OutcomeFatty Liver (n = 29), n (%)Alcoholic Hepatitis (n = 17), n (%)Cirrhosis (n = 34), n (%)p-Value
Alive26 (89.7%)10 (58.8%)15 (44.1%)<0.001 *
Deceased3 (10.3%)6 (35.3%)15 (44.1%)
Unknown †0 (0.0%)1 (5.9%)4 (11.8%)
Percentages reflect proportions within each ALD stage. * Indicates statistical significance (p < 0.05, chi-square test). † The patient was lost to follow-up.
Table 5. Causes of death by alcoholic liver disease stage (n = 24).
Table 5. Causes of death by alcoholic liver disease stage (n = 24).
CauseFatty Liver (n = 3), n (%)Alcoholic Hepatitis (n = 6), n (%)Cirrhosis (n = 15), n (%)p-Value
Sepsis1 (33.3%)2 (33.3%)6 (40.0%)0.95
Massive UGIB1 (33.3%)2 (33.3%)4 (26.7%)0.89
HRS0 (0.0%)0 (0.0%)2 (13.3%)0.47
Perforated PUD0 (0.0%)0 (0.0%)1 (6.7%)0.99
Trauma (fall)0 (0.0%)1 (16.7%)0 (0.0%)0.18
Unknown1 (33.3%)1 (16.7%)2 (13.3%)—
Abbreviations: UIGB, upper intestinal gastrointestinal bleeding; HRS, hepatorenal syndrome. Percentages reflect proportions of deaths within each ALD stage. Fisher’s exact test was used due to small cell counts; no significant differences were observed.
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Al-Busafi, S.A.; Al Baluki, T.A.; Alwassief, A. Patterns and Outcomes of Alcoholic Liver Disease (ALD) in Oman: A Retrospective Study in a Culturally Conservative Context. Livers 2025, 5, 38. https://doi.org/10.3390/livers5030038

AMA Style

Al-Busafi SA, Al Baluki TA, Alwassief A. Patterns and Outcomes of Alcoholic Liver Disease (ALD) in Oman: A Retrospective Study in a Culturally Conservative Context. Livers. 2025; 5(3):38. https://doi.org/10.3390/livers5030038

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Al-Busafi, Said A., Thuwiba A. Al Baluki, and Ahmed Alwassief. 2025. "Patterns and Outcomes of Alcoholic Liver Disease (ALD) in Oman: A Retrospective Study in a Culturally Conservative Context" Livers 5, no. 3: 38. https://doi.org/10.3390/livers5030038

APA Style

Al-Busafi, S. A., Al Baluki, T. A., & Alwassief, A. (2025). Patterns and Outcomes of Alcoholic Liver Disease (ALD) in Oman: A Retrospective Study in a Culturally Conservative Context. Livers, 5(3), 38. https://doi.org/10.3390/livers5030038

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