Acute alcoholic hepatitis

(Redirected from Alcoholic hepatitis)

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

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]

Disposition

Discharge

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

Admit

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[7]

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. O'Shea RS, Dasarathy S, McCullough AJ (2010) Alcoholic liver disease. Hepatology 51: 307–328. doi: 10.1002/hep.23258