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Acute alcoholic hepatitis/en - Revision history
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==Background==<br />
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Acute alcoholic hepatitis is inflammatory liver disease secondary to alcohol use. <br />
*Spectrum from hepatic steatosis to alcoholic hepatitis to [[Special:MyLanguage/cirrhosis|cirrhosis]]<br />
*History of (usually chronic) [[Special:MyLanguage/alcohol Abuse|alcohol abuse]] (~80 grams of ethanol daily for 5 years)<br />
*Ranges from subclinical cases to severe multisystem dysfunction<br />
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==Clinical Features==<br />
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[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]<br />
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]<br />
[[File:Hepaticfailure.jpg|thumb|[[Special:MyLanguage/Ascites|Ascites]] secondary to cirrhosis.]]<br />
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===Symptoms===<br />
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*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]<br />
*[[Special:MyLanguage/Nausea and vomiting|Nausea and vomiting]]<br />
*Weight loss / fatigue / anorexia<br />
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===Signs===<br />
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*[[Special:MyLanguage/RUQ tenderness|RUQ tenderness]]<br />
*[[Special:MyLanguage/Jaundice|Jaundice]]<br />
*[[Special:MyLanguage/Fever|Fever]]<br />
*[[Special:MyLanguage/Hepatomegaly|Hepatomegaly]]<br />
*[[Special:MyLanguage/Ascites|Ascites]]<br />
*[[Special:MyLanguage/Encephalopathy|Encephalopathy]]<br />
*Spider angioma<br />
*[[Special:MyLanguage/GI bleed|GI bleed]]/varices<br />
*[[Special:MyLanguage/Malnutrition|Malnutrition]] <br />
*Symptoms of [[Special:MyLanguage/alcohol withdrawal|alcohol withdrawal]]<br />
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[[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><br />
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==Differential Diagnosis==<br />
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*Alcoholic [[Special:MyLanguage/pancreatitis|pancreatitis]]<br />
*[[Special:MyLanguage/Gallstones|Gallstones]]<br />
*[[Special:MyLanguage/Budd-Chiari syndrome|Budd-Chiari syndrome]]<br />
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]<br />
*Drug-induced hepatitis<br />
{{Acute hepatitis causes}}<br />
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==Evaluation==<br />
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[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]<br />
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]]<br />
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===Work Up===<br />
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====Labs====<br />
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*CBC<br />
**[[Special:MyLanguage/Leukocytosis|Leukocytosis]] with elevated ANC <br />
*Chemistry including magnesium and phosphate<br />
*[[Special:MyLanguage/LFTs|LFTs]]<br />
**Very high elevations possibly more suggestive of viral or drug-induced hepatitis<br />
**Elevated AST/ALT (characteristically >2:1 and < 500 IU/L)<br />
**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><br />
*Coagulation factors<br />
**Elevated PT/INR<br />
*Lipase if suspect [[Special:MyLanguage/pancreatitis|pancreatitis]]<br />
*Consider [[Special:MyLanguage/viral hepatitis|viral hepatitis]] panel<br />
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====Imaging====<br />
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*Consider [[ultrasound: Abdomen|transabdominal ultrasound]] if concern for:<br />
**[[Special:MyLanguage/biliary disease|Biliary obstruction]]<br />
**[[Special:MyLanguage/Budd-Chiari syndrome|Budd-Chiari syndrome]] <br />
**Hepatic or biliary neoplasms<br />
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===Evaluation===<br />
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*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><br />
**History of significant alcohol intake<br />
**Clinical evidence of liver disease<br />
**Supporting laboratory abnormalities <br />
***May be nondiagnostic in patients with mild disease or early cirrhosis<br />
*May also have electrolyte abnormalities from malnutrition or [[Special:MyLanguage/alcoholic ketoacidosis|alcoholic ketoacidosis]]<br />
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==Management==<br />
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*Control of withdrawal symptoms<br />
*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<br />
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===Severe Alcoholic Hepatitis===<br />
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*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><br />
**Confers mortality of 20-50% in 30 days<br />
*1st line therapy: '''[[Special:MyLanguage/Prednisolone|Prednisolone]] 40mg PO qDay x4wks'''<ref name=Singal2018 /><br />
**Must assess response to treatment at 7 days with Lille score<br />
***If '''Lille score >0.45''', considered as non-responder and prednisolone should be discontinued<ref name=Singal2018 /><br />
*[[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><br />
*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><br />
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==Disposition==<br />
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===Discharge===<br />
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*Mild disease/low risk<br />
*Nutritional assessment and intervention<br />
*Discuss [[Special:MyLanguage/alcohol|alcohol]] use and recommend strict abstinence<br />
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===Admit===<br />
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*High risk defined as MDF ≥ 32, MELD ≥ 18, or presence of [[Special:MyLanguage/hepatic encephalopathy|hepatic encephalopathy]]<br />
*Admission should be considered for the above as well as any of the following complications:<br />
**Evidence of active infection<br />
**Renal failure<br />
**Severe coagulopathy and/or liver failure<br />
**Alcohol withdrawal/delirium tremens<br />
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==Prognosis==<br />
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*Maddrey Discriminant Function score ([http://www.mdcalc.com/maddreys-discriminant-function-for-alcoholic-hepatitis/ MDF])<br />
*Model for End-Stage Liver Disease score ([http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD])<br />
*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><br />
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==See Also==<br />
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*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]<br />
*[[Special:MyLanguage/Alcohol|Alcohol]]<br />
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==External Links==<br />
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*http://www.aasld.org/sites/default/files/guideline_documents/AlcoholicLiverDisease1-2010.pdf<br />
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==References==<br />
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<references/><br />
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[[Category:GI]]</div>
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