Skip to content

Alcoholic Hepatitis

Ahmad Yanis

Background

  • Acute onset of rapidly progressive jaundice (within prior 8 weeks) in pt with heavy EtOH intake (>40g in females or >60g in males EtOH/day for >6 mos, or within <60 days of abstinence)
    • May present after they have quit drinking due to immunosuppressive effects of alcohol
    • Risk Factors: Female, Hispanic ethnicity, binge drinking, poor nutrition, and obesity

Evaluation

  • AST >60, AST/ALT >1.5, both values <400 IU/L; TBili >3.0 mg/dL, documentation of heavy EtOH use until 8 weeks prior to presentation (some guidelines state 12 weeks)
  • Prognostication with Maddrey’s Discriminant Function: 4.6 * (PTpt – PTctrl) + Tbili
    • Maddrey > 32 or MELD > 20 = poor 30d prognosis & may benefit from steroids (see below)
  • RUQ U/S to rule out obstructive cause of jaundice
  • Biopsy is not typically required but will show neutrophilic lobular inflammation, hepatocyte ballooning, steatosis, and pericellular fibrosis.
  • Phosphatidylethanol (PEth) level is a biomarker of ethanol consumption over ~ 4wks; >20 ng/mL can indicate chronic moderate/heavy alcohol intake
    • A single episode consumption can result in detectable Peth for up to 12 days. Can be elevated for months with regular heavy alcohol intake
    • EtOH levels may be negative unless acutely intoxicated

Management

  • Supportive Care is essential! Consult nutrition, start high protein, high calorie diet, high dose Thiamine x 3d, Folate, MVI
  • Full infection workup (CXR, UA, BCx, paracentesis) regardless of symptoms
  • Steroids:
    • Discuss with hepatology team, >20 clinical trials conducted with inconsistent results
      • Largest trial was the STOP-AH Trial (NEJM 2015) which showed improved mortality at 28 days in post hoc analysis, but not at 90 days in patients with Maddrey > 32.
      • VA trial (patients with MDF >54) showed increased mortality, indicating a possible ceiling at which point steroids may be harmful.
    • Individuals with a neutrophil: lymphocyte ratio of 5-8 are most likely to benefit from steroid use.
    • Treatment dose is prednisolone 40mg daily (preferred over prednisone as it requires hepatic metabolism)
      • Contraindications to steroids include: presence of infection (must rule out first including TB, active Hep B, sepsis, uncontrolled GI bleeding, AKI w/ Cr >2.5 mg/dL) - The Lille score can be used to assess response to steroids after 7 d of therapy and prognosticate mortality at 6 months
      • Lille > 0.45 indicates no response to steroids and predicts 75% mortality at 6 months
    • NAC should be considered as adjunctive therapy to steroids
  • Monitor on CIWA
    • Psychiatry consultation as appropriate, consideration of medical therapy (see “Substance Use Disorders” section in psychiatry)