Acute alcoholic hepatitis: Difference between revisions
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==Background==
<languages/>
<translate>
 
==Background== <!--T:1-->
 
<!--T:2-->
Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use.   
Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use.   
*Spectrum from hepatic steatosis to alcoholic hepatitis to cirrhosis
*Spectrum from hepatic steatosis to alcoholic hepatitis to [[Special:MyLanguage/cirrhosis|cirrhosis]]
*History of (usually chronic) alcohol abuse (~80 grams of ethanol daily for 5 years)
*History of (usually chronic) [[Special:MyLanguage/alcohol Abuse|alcohol abuse]] (~80 grams of ethanol daily for 5 years)
*Ranges from subclinical cases to severe multisystem dysfunction
*Ranges from subclinical cases to severe multisystem dysfunction


==Clinical Features==
 
==Clinical Features== <!--T:3-->
 
<!--T:4-->
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
===Symptoms===
[[File:Hepaticfailure.jpg|thumb|[[Special:MyLanguage/Ascites|Ascites]] secondary to cirrhosis.]]
*[[Abdominal pain]]
 
*[[Nausea and vomiting]]
===Symptoms=== <!--T:5-->
 
<!--T:6-->
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*[[Special:MyLanguage/Nausea and vomiting|Nausea and vomiting]]
*Weight loss / fatigue / anorexia
*Weight loss / fatigue / anorexia


===Signs===
 
*[[RUQ tenderness]]
===Signs=== <!--T:7-->
*[[Jaundice]]
 
*[[Fever]]
<!--T:8-->
*[[Hepatomegaly]]
*[[Special:MyLanguage/RUQ tenderness|RUQ tenderness]]
*[[Ascites]]
*[[Special:MyLanguage/Jaundice|Jaundice]]
*[[Encephalopathy]]
*[[Special:MyLanguage/Fever|Fever]]
*[[Special:MyLanguage/Hepatomegaly|Hepatomegaly]]
*[[Special:MyLanguage/Ascites|Ascites]]
*[[Special:MyLanguage/Encephalopathy|Encephalopathy]]
*Spider angioma
*Spider angioma
*[[GI bleed]]/varices
*[[Special:MyLanguage/GI bleed|GI bleed]]/varices
*Malnutrition  
*[[Special:MyLanguage/Malnutrition|Malnutrition]]
*Symptoms of [[alcohol withdrawal]]
*Symptoms of [[Special:MyLanguage/alcohol withdrawal|alcohol withdrawal]]
 
<!--T:9-->
[[Special:MyLanguage/Cirrhosis|Cirrhosis]] is found in 50-60% of cases of alcoholic hepatitis<ref>Basra, Gurjot,et. al.  "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.</ref>
 


Cirrhosis is found in 50-60% of cases of alcoholic hepatitis<ref>Basra, Gurjot,et. al.  "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.</ref>
==Differential Diagnosis== <!--T:10-->


==Differential Diagnosis==
<!--T:11-->
*Alcoholic [[pancreatitis]]
*Alcoholic [[Special:MyLanguage/pancreatitis|pancreatitis]]
*[[Gallstones]]
*[[Special:MyLanguage/Gallstones|Gallstones]]
*[[Budd-Chiari syndrome]]
*[[Special:MyLanguage/Budd-Chiari syndrome|Budd-Chiari syndrome]]
*[[Viral hepatitis]]
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]
*Drug-induced hepatitis
*Drug-induced hepatitis
</translate>
{{Acute hepatitis causes}}
{{Acute hepatitis causes}}
<translate>
==Evaluation== <!--T:12-->
<!--T:13-->
[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]]
===Work Up=== <!--T:14-->
====Labs==== <!--T:15-->


==Evaluation==
<!--T:16-->
===Work Up===
====Labs====
*CBC
*CBC
**Leukocytosis with elevated ANC  
**[[Special:MyLanguage/Leukocytosis|Leukocytosis]] with elevated ANC  
*Chemistry including magnesium and phosphate
*Chemistry including magnesium and phosphate
*LFTs - very high elevations possibly more suggestive of viral or drug-induced hepatitis
*[[Special:MyLanguage/LFTs|LFTs]]
**Very high elevations possibly more suggestive of viral or drug-induced hepatitis
**Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
**Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
**GGT alone is less reliable (low sensitivity and specificity)<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
**GGT alone is less reliable (low sensitivity and specificity)<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
*Coagulation factors
*Coagulation factors
**Elevated PT/INR
**Elevated PT/INR
*Lipase if suspect pancreatitis
*Lipase if suspect [[Special:MyLanguage/pancreatitis|pancreatitis]]
*Consider hepatitis panel
*Consider [[Special:MyLanguage/viral hepatitis|viral hepatitis]] panel


====Imaging====
Consider transabdominal ultrasound if concern for:
*Biliary obstruction
*Budd-Chiari syndrome
*Hepatic or biliary neoplasms


===Evaluation===
====Imaging==== <!--T:17-->
Diagnosis is difficult and relies on a good history<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
*History of significant alcohol intake
*Clinical evidence of liver disease
*Supporting laboratory abnormalities
**May be nondiagnostic in patients with mild disease or early cirrhosis


==Management==
<!--T:18-->
*Consider [[ultrasound: Abdomen|transabdominal ultrasound]] if concern for:
**[[Special:MyLanguage/biliary disease|Biliary obstruction]]
**[[Special:MyLanguage/Budd-Chiari syndrome|Budd-Chiari syndrome]]
**Hepatic or biliary neoplasms
 
 
===Evaluation=== <!--T:19-->
 
<!--T:20-->
*Diagnosis is difficult and relies on a good history<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
**History of significant alcohol intake
**Clinical evidence of liver disease
**Supporting laboratory abnormalities
***May be nondiagnostic in patients with mild disease or early cirrhosis
*May also have electrolyte abnormalities from malnutrition or [[Special:MyLanguage/alcoholic ketoacidosis|alcoholic ketoacidosis]]
 
 
==Management== <!--T:21-->
 
<!--T:22-->
*Control of withdrawal symptoms
*Control of withdrawal symptoms
*Nutritional support for malnutrition: especially thiamine, folate, pyridoxine, magnesium, phosphate, glucose, and protein
*Nutritional support for malnutrition: especially [[Special:MyLanguage/thiamine|thiamine]], [[Special:MyLanguage/folate|folate]], [[Special:MyLanguage/pyridoxine|pyridoxine]], [[Special:MyLanguage/magnesium|magnesium]], [[Special:MyLanguage/hypophosphatemia|phosphate]], [[Special:MyLanguage/dextrose|glucose]], and protein
 
 
===Severe Alcoholic Hepatitis=== <!--T:23-->
 
<!--T:24-->
*Defined as '''Maddrey's DF score ≥32'''<ref name=Singal2018>Singal AK, et. al. ACG clinical guideline: alcoholic liver disease. Am J Gastro. 2018; 113: 175-194.</ref>
**Confers mortality of 20-50% in 30 days
*1st line therapy: '''[[Special:MyLanguage/Prednisolone|Prednisolone]] 40mg PO qDay x4wks'''<ref name=Singal2018 />
**Must assess response to treatment at 7 days with Lille score
***If '''Lille score >0.45''', considered as non-responder and prednisolone should be discontinued<ref name=Singal2018 />
*[[Special:MyLanguage/Pentoxifylline|Pentoxifylline]] - evidence does not support its use<ref>Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. JAMA. 2013;310(10):1033-41.</ref>
*Discontinue nonselective beta blockers (e.g., propranolol) to lower incidence of AKI<ref> Sersté T, Njimi H, Degré D, Deltenre P, Schreiber J, Lepida A, Trépo E, Gustot T, Moreno C. The use of beta-blockers is associated with the occurrence of acute kidney injury in severe alcoholic hepatitis. Liver Int. 2015 Aug;35(8):1974-82. doi: 10.1111/liv.12786. Epub 2015 Feb 4. PMID: 25611961.</ref>
 


===High risk, severe cases===
==Disposition== <!--T:25-->
*[[Steroids]]
*[[Pentoxifylline]] - may not provide any added benefit<ref>Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. JAMA. 2013;310(10):1033-41.</ref>


==Disposition==
*Discharge
**Mild disease/low risk
**Nutritional assessment and intervention
**Discuss [[alcohol]] use and recommend strict abstinence
*Admit
**High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of [[hepatic encephalopathy]]


==Prognosis==
===Discharge=== <!--T:26-->
 
<!--T:27-->
*Mild disease/low risk
*Nutritional assessment and intervention
*Discuss [[Special:MyLanguage/alcohol|alcohol]] use and recommend strict abstinence
 
 
===Admit=== <!--T:28-->
 
<!--T:29-->
*High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of [[Special:MyLanguage/hepatic encephalopathy|hepatic encephalopathy]]
*Admission should be considered for the above as well as any of the following complications:
**Evidence of active infection
**Renal failure
**Severe coagulopathy and/or liver failure
**Alcohol withdrawal/delirium tremens
 
 
==Prognosis== <!--T:30-->
 
<!--T:31-->
*Maddrey Discriminant Function score ([http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/ MDF])
*Maddrey Discriminant Function score ([http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/ MDF])
*Model for End-Stage Liver Disease score ([http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD])
*Model for End-Stage Liver Disease score ([http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD])
*High risk: MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>
*High risk: MDF ≥ 32, MELD ≥ 18, or presence of [[Special:MyLanguage/hepatic encephalopathy|hepatic encephalopathy]]<ref>O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258</ref>


==See Also==
*[[Acute hepatitis]]
*[[Alcohol]]


==External Links==
==See Also== <!--T:32-->
 
<!--T:33-->
*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
*[[Special:MyLanguage/Alcohol|Alcohol]]
 
 
==External Links== <!--T:34-->
 
<!--T:35-->
*http://www.aasld.org/sites/default/files/guideline_documents/AlcoholicLiverDisease1-2010.pdf
*http://www.aasld.org/sites/default/files/guideline_documents/AlcoholicLiverDisease1-2010.pdf


==References==
 
==References== <!--T:36-->
 
<!--T:37-->
<references/>
<references/>


<!--T:38-->
[[Category:GI]]
[[Category:GI]]
</translate>

Latest revision as of 16:57, 6 January 2026

Other languages:

Background

Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use.

  • Spectrum from hepatic steatosis to alcoholic hepatitis to cirrhosis
  • History of (usually chronic) alcohol abuse (~80 grams of ethanol daily for 5 years)
  • Ranges from subclinical cases to severe multisystem dysfunction


Clinical Features

Jaundice of the skin
Spider angioma
Ascites secondary to cirrhosis.

Symptoms


Signs

Cirrhosis is found in 50-60% of cases of alcoholic hepatitis[1]


Differential Diagnosis


Causes of acute hepatitis


Evaluation

Ascites appearance on ultrasound
Liver cirrhosis with ascites on CT

Work Up

Labs

  • CBC
  • Chemistry including magnesium and phosphate
  • LFTs
    • Very high elevations possibly more suggestive of viral or drug-induced hepatitis
    • Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)
    • GGT alone is less reliable (low sensitivity and specificity)[3]
  • Coagulation factors
    • Elevated PT/INR
  • Lipase if suspect pancreatitis
  • Consider viral hepatitis panel


Imaging


Evaluation

  • Diagnosis is difficult and relies on a good history[4]
    • History of significant alcohol intake
    • Clinical evidence of liver disease
    • Supporting laboratory abnormalities
      • May be nondiagnostic in patients with mild disease or early cirrhosis
  • May also have electrolyte abnormalities from malnutrition or alcoholic ketoacidosis


Management


Severe Alcoholic Hepatitis

  • Defined as Maddrey's DF score ≥32[5]
    • Confers mortality of 20-50% in 30 days
  • 1st line therapy: Prednisolone 40mg PO qDay x4wks[5]
    • Must assess response to treatment at 7 days with Lille score
      • If Lille score >0.45, considered as non-responder and prednisolone should be discontinued[5]
  • Pentoxifylline - evidence does not support its use[6]
  • Discontinue nonselective beta blockers (e.g., propranolol) to lower incidence of AKI[7]


Disposition

Discharge

  • Mild disease/low risk
  • Nutritional assessment and intervention
  • Discuss alcohol use and recommend strict abstinence


Admit

  • High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy
  • Admission should be considered for the above as well as any of the following complications:
    • Evidence of active infection
    • Renal failure
    • Severe coagulopathy and/or liver failure
    • Alcohol withdrawal/delirium tremens


Prognosis

  • Maddrey Discriminant Function score (MDF)
  • Model for End-Stage Liver Disease score (MELD)
  • High risk: MDF ≥ 32, MELD ≥ 18, or presence of hepatic encephalopathy[8]


See Also


External Links


References

  1. ↑ Basra, Gurjot,et. al. "Symptoms and Signs of Acute Alcoholic Hepatitis." World J Hepatol. 2011 May 27; 3(5): 118–120.
  2. ↑ Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
  3. ↑ O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
  4. ↑ O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
  5. ↑ 5.0 5.1 5.2 Singal AK, et. al. ACG clinical guideline: alcoholic liver disease. Am J Gastro. 2018; 113: 175-194.
  6. ↑ Mathurin P, Louvet A, Duhamel A, et al. Prednisolone with vs without pentoxifylline and survival of patients with severe alcoholic hepatitis: a randomized clinical trial. JAMA. 2013;310(10):1033-41.
  7. ↑ Sersté T, Njimi H, Degré D, Deltenre P, Schreiber J, Lepida A, Trépo E, Gustot T, Moreno C. The use of beta-blockers is associated with the occurrence of acute kidney injury in severe alcoholic hepatitis. Liver Int. 2015 Aug;35(8):1974-82. doi: 10.1111/liv.12786. Epub 2015 Feb 4. PMID: 25611961.
  8. ↑ O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258
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